National Institute on Drug Abuse

RESEARCH

MONOGRAPH SERIES

Therapeutic

Community:

Advances in

Research

and Application

U.S. Department of Health and Human Services • Public Health Service • National Institutes of Health

144
Therapeutic Community:

Advances in Research and

Application

Editors:

Frank M. Tims, Ph.D.

Division of Clinical Research

National Institute on Drug Abuse

George De Leon, Ph.D.

Center for Therapeutic Community Research

National Development and Research Institutes

Nancy Jainchill, Ph.D.

Center for Therapeutic Community Research

National Development and Research Institutes

NIDA Research Monograph 144

1994

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 20857
ACKNOWLEDGMENT

This monograph is based on the papers from a technical review on

“Therapeutic Community: Advances in Research and Application”

held on May 16-17, 1991. The review meeting was sponsored by the

National Institute on Drug Abuse.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission from the

copyright holders to reproduce certain previously published material as

noted in the text. Further reproduction of this copyrighted material is

permitted only as part of a reprinting of the entire publication or chapter.

For any other use, the copyright holder’s permission is required. All

other material in this volume except quoted passages from copyrighted

sources is in the public domain and may be used or reproduced without

permission from the Institute or the authors. Citation of the source is

appreciated.

Opinions expressed in this volume are those of the authors and do not

necessarily reflect the opinions or official policy of the National Institute

on Drug Abuse or any other part of the U.S. Department of Health and

Human Services.

The U.S. Government does not endorse or favor any specific commercial

product or company. Trade, proprietary, or company names appearing in

this publication are used only because they are considered essential in the

context of the studies reported herein.

National Institute on Drug Abuse

NIH Publication No. 94-3633

Printed 1994

NIDA Research Monographs are indexed in the Index Medicus. They are

selectively included in the coverage of American Statistics Index,

BioSciences Information Service, Chemical Abstracts, Current Contents

Psychological Abstracts, and Psychopharmacology Abstracts.

ii
Contents

Page

Therapeutic Communities and Treatment Research . . . . . . . . . . .

Frank M. Tims, Nancy Jainchill, and George De Leon

1

The Therapeutic Community: Toward a General

Theory and Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

George De Leon

Socialization Into the Therapeutic Community Culture . . . . . . . .

Lorand Szalay

Client Outcomes From Therapeutic Communities . . . . . . . . . . . .

Ward S. Condelli and Robert L. Hubbard

16

54

80

Retention in Therapeutic Communities: Challenges

for the Nineties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Benjamin F. Lewis and Roy Ross

Predictors of Retention in Therapeutic Communities . . . . . . . . . .

Ward S. Condelli

Adolescents in Therapeutic Communities: Retention

and Posttreatment Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kenneth F. Pompi

99

117

128

Therapeutic Communities: Substance Abuse

Treatment for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Sally J. Stevens and Peggy J. Glider

Therapeutic Communities in Prison . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Harry K. Wexler and Craig T. Love

iii
Co-Morbidity and Therapeutic Community Treatment . . . . . . . . . . . 209

Nancy Jainchill

HIV and Therapeutic Communities . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Jane McCusker and James L. Sorensen

Therapeutic Communities in Corrections and Work Release:

Some Clinical and Policy Considerations . . . , . . . . . . . . . . . . . . . . . 259

James A. Inciardi, Dorothy Lockwood, and Steven S. Martin

Clinical Issues in Therapeutic Communities . . . . . . . . . . . . . . . . . . . 268

Jerome F.X. Carroll

Therapeutic Community Research and Practice:

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Frank M. Tims, George De Leon, and Nancy Jainchill

iv
Therapeutic Communities and

Treatment Research

Frank M. Tims, Nancy Jainchill, and George De Leon

INTRODUCTION

Programs to treat drug abuse and addiction/dependence are a relatively

recent innovation. Drug abuse programs emerged in an organized way in

the 1960s as a response to this major social and public health problem in

the United States. Mainstream organized health care was not prepared,

either intellectually or organizationally, to respond to the drug abuse

epidemic; thus, an alternative system developed. The growth of treatment

facilities in the 1960s and 1970s reflected differing views of the nature of

drug abuse and addiction and what was required to treat it effectively.

Aside from detoxification units, which were intended to provide the first

step in treatment but more commonly provided only a brief respite from

the rigors of addiction, three modalities emerged as the dominant

treatment types for drug abusers: drug-free outpatient programs;

outpatient methadone maintenance programs; and long-term, drug-free

residential programs called therapeutic communities (TCs). More

recently, short-term residential programs using 12-step or other non-TC

approaches have emerged (Institute of Medicine 1990).

TREATING DRUG PROBLEMS

This monograph grew out of a technical review meeting that took place in

May 1991. The technical review was convened by the National Institute

on Drug Abuse (NIDA) for the purpose of systematically examining the

TC modality and the existing body of research on TC treatment, to

review and consolidate knowledge about this modality, and to chart

future directions in TC research. While the TC is a major modality that is

unique in its view and application of treatment, research in this modality

also has implications for other modalities; in fact, methods developed in

TCs have been applied in other programs (De Leon et al. 1993).

In addition to reviewing the TC research base to guide future lines of

investigation, the goal of the technical review was to involve the TC

movement’s practitioners to the greatest extent feasible. An essential

1
feature of research on treatment programs and modalities is the active

cooperation of practitioners as partners in the research enterprise. These

practitioners are in a position to facilitate the research, to offer insights

during its planning and conceptualization, to provide guidance on critical

issues and questions, and to provide feedback on analytic interpretations.

As users of applied research, TC practitioners can help focus research so

that it is truly useful.

Thus, it was decided to invite the Therapeutic Communities of America

(TCA) to attend the meeting, to form three panels (research, clinical, and

administrative), and to report back to the group during the final phase of

the meeting. Although the TCA reports are not contained in this

monograph, they were useful in developing the recommendations

contained in the final chapter.

TC PROGRAMS

TC programs reflect a view of the drug abuse client as having a social

deficit and requiring social treatment. This social treatment may be

characterized as an organized effort to resocialize the client, with the

community as an agent of personal change. There has been much

folklore and misinformation about TCs. They are viewed by some as

isolated from the mainstream of drug abuse treatment, antagonistic

toward medications in drug abuse treatment, and not generally receptive

to research. Regarding the first point, TCs have evolved from a self-help

perspective as a social movement. Because TCs utilize a social treatment

approach, their leaders and practitioners have not tended to have medical

credentials. Indeed, given their history and self-help perspective, TC staff

(at all levels) have included ex-addicts, social activists, and health

professionals.

It should be noted that all drug abuse treatment modalities have evolved

in a rather short span of time, and TCs are generally accepted by

practitioners in other modalities as a legitimate treatment approach.

Existing drug abuse treatment modalities evolved in response to a need

that the mainstream health care system was not meeting, and the

evolution of these modalities is in the direction of integration. While

medications, notably methadone, are not generally part of TC treatment,

some TCs permit appropriate use of psychotropic medications under

medical supervision, as long as they do not pose a threat to the abstinence

norms that are therapeutically important. It also is important to note that,

2
while many TCs may not have research departments, much of the

existing research in the drug abuse literature was carried out in

cooperation with TC programs. In fact, some of the early landmark

studies on treatment effectiveness were carried out by TC researchers

(Collier and Hijazi 1974; De Leon 1984).

TCs tend to share a similar view of the client, an emphasis on structure

and hierarchy within the program, a need to isolate the individual from

competing influences during treatment, a need for a prolonged period of

treatment that is phased and intensive, and clear norms regarding personal

responsibility and behavior which form the core of treatment. Learning,

accepting, and internalizing these norms is accomplished through a

highly structured treatment process that requires active participation by

the client in a context of confrontation (to address denial, false beliefs,

and defense mechanisms), mutual self-help, and affirmation of program

expectations. Thus, as De Leon points out in the following chapter,

community is treatment. The therapeutic process involves the group (the

community) constantly, but also must involve the individual. An

aphorism of the TC movement is,“Only you can do it, but you can’t do it

alone.”

MAJOR AREAS OF FOCUS

Not all residential drug treatment programs are TCs, and it is not clear

that all TCs follow the same model. The existing programs that call

themselves TCs have an organized movement and both national (TCA)

and international (World Federation of Therapeutic Communities) levels.

What are the essential characteristics of a TC? De Leon (this volume) has

attempted to delineate a general theoretical model of the TC. The TC

perspective is reviewed in terms of its view of the disorder, the person,

right living, and recovery. Drug abuse is viewed as a disorder of the

whole person, and individuals are distinguished along dimensions of

psychological dysfunction and social deficits. Recovery is viewed as a

developmental process that requires the integration of explicit social and

psychological goals.

What distinguishes the TC from other treatment approaches is the

purposeful use of the community as the primary method for facilitating

growth and change in individuals. There are four dimensions of

behavioral (objective) change: The dimensions of community member

and socialization are concerned with the individual’s social development;

3
the developmental and psychological dimensions refer to the evolution of

the individual in terms of maturity, emotional skills, and identity. The

subjective aspects of behavioral change are the individual’s essential

perceptions and experiences related to the following: (1) circumstances

(external pressures); (2) motivation (inner reasons for personal change);

(3) readiness (treatment is the only option); (4) suitability (self-perceived

match between the person and the treatment); and (5) critical perceptions

of self-change (e.g., self-efficacy, self-esteem). Essential experiences

include healing experiences (nurturance, physical and psychological

safety); subjective learning experiences (self-evaluative perceptions,

thoughts, and feelings necessary for achieving internalized learning); and

critical therapeutic experiences (e.g., distinctive therapeutic events). The

change process in the TC incorporates behavioral and social learning

principles with the essential experiences and perceptions as mechanisms

in the process. Change is viewed from a behavioral orientation that

includes the community as trainer, efficacy training, social role training,

and vicarious learning. The stages of change are reviewed and

distinguished along three perspectives: recovery, the program, and

treatment. The last stage of treatment, integration, is an evolving process

that begins in treatment; however, it emerges mainly after separation from

the program, which underscores the interrelation between TC influences

and broader life experiences. Integration is the last phase of the learning

process, which is preceded in order by compliance, conformity, and

commitment. A distinctive marker of the integration stage is a change in

identity that is perceived by the individual and others. This change in

identity reflects the importance of learning that is internalized and that

characterizes the integration phase.

In addition to clarifying the TC as a model and recognizing that different

varieties exist, it is important to examine a range of questions about client

populations served, services and treatment processes, cultural aspects, and

outcomes. Issues of planned change and the potential of science to

improve the TC modality also are of interest.

Carroll, in his chapter, examines the clinical issues that confront the TC

field. He calls for collaborative efforts among researchers,

administrators, and clinicians in the design and implementation of studies

and interpretation of findings. Some fundamental research issues that

need to be considered include: (1) delineation of the guiding principles

and practices that distinguish the TC field; (2) the role and impact of

integrating professionals into the TC; (3) description of the spectrum of

clients in treatment; (4) reassessment of recommended lengths of stay in

4
relation to client characteristics and the different varieties of treatment

experience; and (5) identification and description of the range of

treatment and rehabilitative services offered in TCs. Carroll also

considers co-morbidity, which he describes as the coexistence of multiple

disorders (substance, mental, and physical), to be the rule among drug

abusers. Comprehensive, holistic treatment approaches employing

multidisciplinary teams within the TC are required to address the

multiplicity of needs of today’s clients. In addition, the importance of

developing new models of addiction and recovery are emphasized.

Carroll advocates the use of an “ecological dysfunction” model that views

behavior as a function of the reciprocal influence of personal and

environmental variables. The value of treatment needs to be

demonstrated by utilizing more realistic and informative concepts of

success, relapse, and dropout.

The effectiveness of the TC has been addressed in numerous outcome

studies (Collier and Hijazi 1974; De Leon 1984; Sells and Simpson

1982). Condelli and Hubbard report the results of outcome research on

TC clients in their chapter. They compare the findings from two national

studies of TCs; compare the characteristics of clients from TCs with other

non-TC long-term residential programs; and assess the relationship

between client characteristics, treatment type (TC versus other long-term

residential), and posttreatment outcomes. Across studies, results have

generally been concordant: Clients who stayed in programs for longer

periods of time had lower rates of drug use and criminal behavior and

higher rates of employment and school attendance than clients who

stayed in programs for shorter periods of time. However, the studies

varied in terms of the amount of time they found clients needed to stay in

programs to produce these positive outcomes, a finding that may be

explained by differences in client populations, program characteristics,

and outcome measures themselves.

Comparisons of outcomes for clients in two national evaluations of drug

abuse treatments provided further evidence for the effectiveness of TCs.

The Drug Abuse Reporting Program (DARP) followup evaluation was

conducted using a sample of clients (most of whom were opoid addicts)

admitted to treatment during 1969-72. A decade later, a similar

study—the Treatment Outcome Prospective Study (TOPS)—was

conducted using a sample of clients admitted to treatment during 1979-

81. The TOPS evaluation included both opiate addicts and polydrug

abusers in the client sample. Both studies found that patterns of

pretreatment versus posttreatment drug use and criminality showed

5
dramatic reductions after treatment, with the more impressive reductions

in drug use being found in the TOPS study. However, the DARP clients

experienced somewhat greater reductions in arrest and incarceration rates

than the TOPS clients.

Admissions to TOPS TCs and other long-term residential programs were

compared. Clients entering TCs were more likely to have been nonHispanic whites and to have had more drug-related problems during the

year before admission. Of note is the fact that time in program (TIP) is a

primary predictor of outcome among TC clients, but it is not a predictor

for admissions to other long-term residential programs. The authors

suggest that time spent in programs is at best only a rough indicator of the

effects of treatment on clients, and they emphasize the need to focus on

variables related to treatment to better understand the relationship

between process and outcome.

A central issue in TC evaluation studies has been the retention of clients

in treatment. Condelli (this volume) examines client and program

variables related to retention. He suggests that certain conceptual and

methodological issues have impeded research from being more useful for

understanding client attrition from drug treatment programs. A

comparison of the three largest studies of retention in TCs and other types

of residential programs showed little overlap among predictors of

retention across the studies. Condelli suggests that these inconsistent

findings are partly by a result of inappropriate comparisons, for example,

a heterogeneity of clients and treatment programs and use of different

measures of retention. The findings of these and other studies indicate

that dynamic client and treatment entry variables are more powerful

predictors of retention than fixed client variables.

In their chapter, Lewis and Ross also address the issue of retention and

time in treatment. The preponderance of research studies have concluded

that there is a positive relationship between the amount of time spent in

TC treatment and successful outcome. Lewis and Ross establish a

framework for a common language that provides more precise and

universally applicable definitions of retention phenomena; review TCbased and other relevant studies of retention phenomena; and identify

critical concerns for the TC field that emerge from these findings. They

have organized their review of retention studies around pretreatment

(e.g., demography, psychopathology, motivation) and within treatment

factors (e.g., program characteristics, treatment events). Research

investigating the relationship of within treatment variables and retention

6
has been limited and should be the focus of future large-scale

multiprogram studies. The nearly universal finding that treatment

outcomes improve as time in treatment increases suggests that researchers

should identify factors that are associated with remaining in treatment.

However, it also is argued that there are negative corrollaries that may

accompany reduced attrition (e.g., reduction in the number of clients who

are exposed to treatment). The enlightenment model (i.e., retention until

graduation) is compared with the compensatory model, which views

recovery as a continuous process involving a chronic condition. The

authors identify the need to ascertain the optimum balance between

retention and treatment.

The central issue of resocialization implies reorienting of perceptions,

values, and frame of reference. This frame of reference question can be

addressed with regard to a core set of values and expectations that are

shared (including those specific to the cultures embedded in particular

TCs, such as those oriented toward Hispanics). It is expected that the

treatment process will evoke changes in the direction of such shared

norms, values, and other common understandings as treatment

progresses. Szalay, in his chapter, explores this central aspect of

treatment and its ramifications for understanding intended change in

treatment programs. He describes the Associative Group Analysis

(AGA) method, which focuses on perceptual and attitudinal dispositions

and on changes in cognitive organization in systems of mental

representation. The systems of subjective representation are charted

along three dimensions: perceptions, dominant priorities, and

attitudes/evaluations. The systems of addicts and rehabilitated clients can

serve as reference groups for determining client status (i.e., how much

their thinking resembles the thinking of rehabilitated individuals). A

cross-sectional comparison of 200 pretreatment and 200 posttreatment

clients at an urban-based TC was used to measure changes in perceptions

and attitudes related to drug use. The pretreatment and posttreatment

groups yielded different response clusters in response to word stimuli.

Szalay suggests three major fields for practical application of the AGA

method: (1) to identify individual and treatment variables that are related

to client success; (2) to monitor client progress along relevant

dimensions, (e.g., self-image, perception of harmful substances); and (3)

to provide empirical insights into perceptual and motivational

dispositions, which are valuable in therapy and counseling.

The role of psychiatric co-morbidity, which has become so common in

drug abuse treatment populations (De Leon 1989; Havassy and

7
Wasserman 1992; Rounsaville et al. 1982; Schottenfeld et al. 1993), is

the focus of the chapter by Jainchill. At one level, it may be seen as a

complication of treatment decisions, but it is so ubiquitous that it is

viewed as a normal part of the array of treatment tasks. Jainchill

suggests that changing trends in drug abuse patterns and drug users

seeking treatment have highlighted the importance of considering

psychological and psychiatric factors in the treatment of substance abuse.

Specific psychiatric disorders, including depression, antisocial behavior,

and borderline personality, appear to occur more frequently among drug

users. Psychological symptoms, as distinguished from psychiatric

disorders established by diagnostic criteria, are generally more transient

and often may be situationally induced. The psychological profiles of

admissions to TCs reflect high levels of depression and anxiety, poor

socialization, deviant Minnesota Multiphasic Personality Inventory

(MMPI) profiles, and low self-esteem. Psychological improvement is

shown by clients who are reexamined during treatment (De Leon 1984,

1988; Holland 1986). Posttreatment psychological status is related to

clients’ length of stay in treatment, with greater improvement seen among

those who stay in treatment longer (De Leon 1984). Favorable social

adjustment also is associated with significant psychological improvement

at followup.

The development of a nosological system to classify disturbances

descriptively and the development of structured instruments to obtain the

diagnoses have facilitated the investigation of the prevalence of

psychiatric disorders among substance abuse populations. Jainchill

(1989) reports that among 350 admissions to a large urban TC, the large

majority had a psychiatric diagnosis at some time in their life, and almost

half had a diagnosis in the month prior to entering treatment. The most

commonly occurring nonsubstance diagnoses were antisocial personality,

psychosexual dysfunction, generalized anxiety, phobias, dysthymia, and

major depression. The relationship between psychiatric disorder and

retention was complex: Longer staying clients tended to have more

history of psychiatric disorder in addition to their substance abuse;

however, psychiatric disturbance in conjunction with low-severity

substance abuse was negatively associated with retention.

The range of treatment populations that are served by TC programs

include some who are treated in specialized programs that are especially

tailored to their unique needs, with the expectation that the mutual peer

support and other aspects of treatment will be appropriate in terms of

form and context. In this volume, Pompi addresses the treatment of

8
adolescents, and Stevens and Glider discuss the needs of women with

children. McCusker and Sorensen review services to human

immunodeficiency virus (HIV)-positive individuals in TCs, and Wexler

and Love describe the application of the TC model to correctional

populations. Inciardi and colleagues also examine the use of the TC in

correctional populations, with a special focus on reentry issues.

A 1989 survey of the TCA membership showed that approximately

one-fifth of TC admissions were 20 years of age or younger. A review

of retention and posttreatment outcome for adolescents in TCs is

provided by Pompi (this volume). He summarizes the findings of nine

data sets, including multimodality studies such as DARP and TOPS, and

single program efforts. TIP varies across the study samples, with the

median TIP ranging between 35 and 96 days. However, the planned

duration of stay varies among the programs, so that the difference in

retention rates is difficult to interpret.

The relationship between adolescent and adult retention rates was

inconsistent; some studies showed similar rates, while others reported

higher or lower retention for adolescents. Among the studies that

reported outcome data, all revealed a positive relationship between TIP

and posttreatment outcomes. These outcome studies indicate reduced

criminal activity and use of opioid and nonopioid drugs, with the

exception of marijuana and alcohol use in one study. In general,

adolescents and adults yield similar posttreatment findings. Two other

studies reported on factors that appear to be related to retention. Biase

(1981) found that higher levels of depression were associated with an

increased likelihood of dropping out of treatment, and Weidman (1987)

reported data supporting the hypothesis that family involvement in the

treatment of adolescents is a potent influence on their retention. The

majority of studies reviewed by Pompi (this volume) included

adolescents who were clients in programs that also served adults. More

recently, TCs have been establishing segregated treatment facilities for

adolescents. The question of treatment segregation versus integration of

adolescent clients needs to be addressed in future studies.

Stevens and Glider (this volume) summarize the development of

specialized programs for women within TCs. Prior to the 1970s, there

was little focus on women’s treatment issues; however, in 1974, NIDA

established a program for women’s concerns. In 1976, Public Law 94-

371 was passed, granting priority considerations for funding of women’s

treatment and prevention services. During the middle to late 1980s, the

9
number of women seeking treatment increased dramatically, the impact

of perinatal substance use became a growing concern, and more services

to women were made available in response. The number of women

stipulated to TC treatment by the legal system underrepresents their

involvement with criminal activity, but it probably reflects the legal

system’s reluctance to mandate women to treatment. Women and men

entering treatment show similar psychological problems; however,

women generally manifest a greater degree of disturbance, often coupled

with histories of incest, molestation, or rape. Nonetheless, women tend to

show greater improvement during and following treatment.

Among 25 TCs that responded to a survey in 1990, 11 reported

specialized programs for women and children. All of the programs

identified the need for parenting education curricula and attention to

sexuality and relationship issues, along with other specialized services.

Specialized programs for women appear to positively impact length of

stay in treatment and increase self-disclosure and the degree of

participation in family issues by men. The cost-effectiveness of treatment

is highlighted by the financial impact to society in terms of medical costs,

the cost of criminal activity, foster care, and educational expenses for

children of substance-abusing parents.

McCusker and Sorensen (this volume) discuss the role of TCs in the

prevention and control of HIV infection among drug users. The median

incubation period between initial infection and development of acquired

immunodeficiency virus (AIDS) is 8 to 10 years. Survival after a

diagnosis of AIDS is short, particularly among injecting drug users

(IDUs) (Harris 1990). TCs can affect primary prevention (i.e., strategies

that reduce HIV transmission) because treatment itself increases

abstinence and can prepare clients for safer relapse through educational

and other interventions (Baker et al. 1993). Treatment and outreach

programs need to coordinate efforts to encourage the admission of highrisk individuals. Studies are needed that will evaluate: (1) the

effectiveness of health education programs and for whom; (2) the impact

of pretreatment HIV status and risky behavior on retention and outcomes;

and (3) the effects of treatment on posttreatment HIV-relevant behaviors.

Secondary prevention strategies involve early detection and prompt

treatment, which may reduce the morbidity and mortality associated with

HIV disease. Studies are needed that compare the effectiveness of

different policies (e.g., contacting partners of individuals who test

positive) related to HIV antibody testing in TCs. Both the effects of

1 0
clients with HIV disease upon the TC and the effects of the TC on the

HIV-infected clients need to be examined.

The aim of tertiary prevention is to provide continuing support and care

to those with advanced HIV disease, to reduce mortality, and to improve

the quality of life. Residential programs recently have begun to address

the special problems of treating HIV-infected clients. Research is needed

to guide informed modifications to the TC in order to accommodate

clients with HIV disease.

Several chapters in this present volume review the effectiveness of TCs

in prisons. Wexler and Love examine the history of TCs in prisons,

provide a summary of empirical evidence for the effectiveness of TCs in

prison, and describe a national technical assistance project (Project

REFORM), which has helped to establish new TCs behind prison walls.

The first prison-based TC, Aesklepieion, was established in 1969 at the

Federal maximum security institution in Marion, IL; it served as a

prototype for other programs, all of which have subsequently closed.

Common problems included lack of communication with other prison

personnel, inadequate supervision, and inadequate staff control. Three

lessons from history guided changes in later prison-based TCs:

(1) improved communication between TC and non-TC institutional

personnel; (2) improved security; and (3) maintenance of control by staff.

The Stay’n Out program, located in two New York State prisons, was the

first in-prison TC to be evaluated. Comparisons with other programs

were favorable, and the relationship between TIP and outcome (e.g.,

percent arrested, positive discharge from parole) was established through

1 year in treatment. Field (1989) reports similar findings among

participants in Cornerstone, a prerelease treatment program for alcoholand drug-dependent offenders in Oregon. The TC approach also has

been successfully employed with youthful offenders in the Wharton Tract

Narcotic Treatment Program in New Jersey (Platt et al. 1980).

Currently, the Federal Bureau of Prisons, in response to the increasing

inmate population that also includes an escalating proportion incarcerated

for drug offenses, offers a hierarchy of programs of increasing intensity.

Project REFORM was established to help State prison systems develop

corrections-based drug treatment programs (Wexler et al. 1991). The

major goal of Project REFORM, which included 11 State prison systems,

was to reduce the amount of crime and drug abuse among incarcerated

offenders after their release. Through 1992, Project Recovery extended

11
offenders after their release. Through 1992, Project Recovery extended

and built on the work of Project REFORM. The essential features of inprison TC programs include: (1) a psychologically safe environment;

(2) recognition and incorporation of cultural and ethnic differences;

(3) program integrity; (4) maintenance of respectful relations with nonTC inmates; (5) maintenance of discipline; (6) the use of ex-addicts and

ex-offenders as program staff, (7) continuity of care; and (8) program

evaluation.

Every prison subculture has a system of norms that typically exert a

greater influence over prisoners’ behaviors than the institution’s formally

prescribed rules. This prison code often imposes sanctions against reform

in general and drug rehabilitation in particular. The TC, as a total

treatment environment apart from the rest of the prison population, has

more opportunity to succeed than other “inside” drug rehabilitation

approaches (Inciardi et at., this volume). The authors suggest that an

effective TC intervention would involve a process involving three stages

that correspond to the inmate’s correctional status (i.e., incarceration,

work release, and parole or other surveillance). The primary stage should

occur in prison, where there is the time and opportunity for

comprehensive treatment. The second stage is a transitional TC,

providing a therapeutic and prosocial milieu for individuals on work

release. The third stage, when the client is back in the free community,

involves counseling, group therapy, and participation in transition

program activities.

CREST Outreach Center, established in late 1990, was the first dedicated

work-release TC in the Nation, and it was designed to incorporate the

three-stage process. The CREST program lasts 26 weeks, and its focus is

to prepare clients for employment, independent living, and return to the

free community. Over a 5-year grant period, CREST will serve

360 inmates selected from both the general prison population and from

the KEY program (Delaware’s prison-based TC), providing an important

opportunity for comparison of different models (e.g., KEY only and KEY

plus CREST).

CONCLUSION

Drug abuse treatment has evolved over a relatively short timespan, with

most of the existing programs emerging over the past three decades. A

variety of perspectives have guided the development of the modalities

12
now available, and the TC approach stands in contrast to the medicationsbased programs such as methadone maintenance and many of the

outpatient counseling programs. The TC modality represents a major

approach to treatment that emphasizes intensive treatment involving a

social perspective and is rooted in a specific view of the disorder, the

person, right living, and recovery. It is a high-demand approach, which is

not suitable for all clients.

Like other modalities, the TC field has developed and undergone change.

The field of drug abuse treatment has become increasingly complex over

the past decades, and the TC movement has responded by becoming

diversified. The TC has been adapted to a variety of environments, and it

has been modified in ways that make it better able to serve the needs of

clients who present with a greater range of problems, including child care

responsibilities, issues of gender and minority cultures, homelessness,

psychiatric co-morbidity, criminal justice involvement, and HIV issues.

An important part of the review presented here is to examine the range of

clients served, the needs of client populations, and the ways in which the

TC field addresses those needs as a dynamic and evolving modality.

REFERENCES

Baker, A.; Heather, N.; Wodak, A.; Dixon, J.; and Holt, P. Evaluation of

a cognitive-behavioral intervention for HIV prevention among

injecting drug users. AIDS 7(2):247-256, 1993.

Biase, D.V. “Advancement in Drug Free Therapeutic Community

Treatment.” Report prepared for National Institute on Drug Abuse

grant no. H81-DA-0911, 1981.

Collier, W.V., and Hijazi, Y.A., A follow-up study of former residents of

a therapeutic community. Int J Addict 9:805-826, 1974.

De Leon, G. Psychopathology and substance abuse: What we are learning

from research in therapeutic communities. J Psychoactive Drugs

21(2):177-188, 1989.

De Leon, G. “Therapeutic Communities: Psychopathology and

Substance Abuse.” Report prepared for National Institute on Drug

Abuse grant no. R01 DA-03860, 1988.

De Leon, G. The Therapeutic Community: Study of Effectiveness.

Treatment Research Monograph Series. DHHS Pub No. (ADM)84-

1286. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984.

13
De Leon, G.; Sacks, S.; and Hilton, R., eds. Passages: A modified

therapeutic community day treatment model for methadone clients.

In: Inciardi, J.A.; Tims, F.M.; and Fletcher, B.W. Innovative

Approaches in the Treatment of Drug Abuse. Wesport, CT:

Greenwood Press, 1993. pp. 125-148.

Field, G. A study of the effects of intensive treatment on reducing the

criminal recidivism of addicted offenders. Federal Probation

53(10):51-56, 1989.

Harris, J.E. Improved short-term survival of AIDS patients initially

diagnosed with Pneumocystis carinii pneumonia, 1984 through 1987.

JAMA 263(3):397-401, 1990.

Havassy, B.E., and Wasserman, D.A. Prevalence of comorbidity among

cocaine users in treatment. In: Harris, L. Problems of Drug

Dependence 1991. National Institute on Drug Abuse Research

Monograph 119. DHHS Pub. No. (ADM)92-1888. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Office, 1992. p. 227.

Holland, S. Mental health and the TC. In: Acampora, A., and Nebelkopf,

E., eds. Proceedings of the Ninth World Conference of Therapeutic

Communities. San Francisco: Bridging Services, 1986. pp. 122-131.

Institute of Medicine. Treating Drug Problems. Washington, DC:

National Academy Press, 1990.

Jainchill, N. “The Relationship Between Psychiatric Disorder, Retention

in Treatment, and Client Progress, Among Admissions to a

Residential, Drug Free Modality.” Ph.D. diss. Ann Arbor, MI: UMI

Dissertation Information Service, 1989.

Platt, J.J.; Perry, G.M.; and Metzger, D.S. The evolution of a heroin

addiction treatment program within a correctional environment. In:

Ross, R.R., and Gendreau, P., eds. Effective Correctional Treatment.

Toronto: Butterworths, 1980.

Rounsaville, B.J.; Weissman, M.M.; Kleber, H.; and Wilber, C.

Heterogeneity of psychiatric diagnosis in treated opiate addicts. Arch

Gen Psychiatry 39:161-166, 1982.

Schottenfeld, R.; Carroll, K.; and Rounsaville, B. Comorbid psychiatric

disorders and cocaine abuse. In: Tims, F.M., and Leukefeld, C.G., eds.

Cocaine Treatment: Research and Clinical Perspectives. NIH Pub.

No. 93-3639. Bethesda, MD: National Institute on Drug Abuse, 1993.

pp. 31-47.

Sells, S.B., and Simpson, D.D. Effectiveness of treatment for drug abuse:

An overview of the DARP research program. Adv Alcohol Subst

Abuse 2(1):7-29, 1982.

14
Weidman, A. Family therapy and reductions in treatment dropout in a

residential therapeutic community for chemically dependent

adolescents. J Subst Abuse Treat 4:21-28, 1987.

Wexler, H.K.; Falkin, G.P.; Lipton, D.S.; and Rosenblum, A.B. Outcome

evaluation of a prison therapeutic community for substance abuse

treatment. In: Leukefeld, C.G., and Tims, F.M., eds. Drug Abuse

Treatment in Prisons and Jails. National Institute on Drug Abuse

Research Monograph 118. DHHS Pub. No. (ADM)92-1884.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992.

AUTHORS

Frank M. Tims, Ph.D.

Chief

Treatment Services Research Branch

Division of Clinical Research

National Institute on Drug Abuse

National Institutes of Health

Parklawn Building, Room 10A-30

5600 Fishers Lane

Rockville, MD 20867

Nancy Jainchill, Ph.D.

Senior Principal Investigator

George De Leon, Ph.D.

Director

Center for Therapeutic Community Research

National Development and Research Institutes

11 Beach Street

New York, NY 10013

15
The Therapeutic Community:

Toward a General Theory and

Model

George De Leon

THE NEED FOR A THERAPEUTIC COMMUNITY THEORY AND

GENERAL MODEL

The maturation of the therapeutic community (TC) as a sophisticated

human services modality is evident in the broad range of programs that

subscribe to the basic TC perspective and approach and serve an

estimated 80,000 admissions yearly. These admissions include a wide

diversity of clients who use an expanded cafeteria of drugs and present

complex social-psychological problems in addition to their chemical

abuse.

The TC’s basic social learning model has been amplified with a variety of

additional services, including family, educational, vocational, medical,

and mental health. Staffing compositions have been altered to include

increasing proportions of traditional mental health, medical, and

educational professionals to serve along with the recovered

paraprofessionals (Carroll and Sobel 1986; De Leon, in press;

Winick 1991).

Correctional institutions, medical and mental hospitals, and community

residence and shelter settings, overwhelmed with alcohol and illicit drug

abuse problems, have implemented TC programs within their institutional

boundaries (Galanter et al. 1993; Wexler and Williams 1986). TC

agencies have incorporated basic elements of its drug-free philosophy and

view of “right living” into educational and prevention programs for

schools and communities.

The evolutionary changes of the TC in the last decade reveal the vigor,

resourcefulness, and flexibility of the modality to adapt to growth and

change. However, evolution also highlights the need for a theoretical

framework and model to advance research and to guide training, practice,

and program development. Currently, this need is most evident in two

16
related issues: the diversity of programs and the complexity of the

treatment process.

The adaptation of TCs for new clients and different settings has resulted

in a proliferation of programs with unique treatment protocols and

different planned durations of stay; even the long-term traditional model

is differentially implemented. The range and extent to which these

adapted programs retain the basic elements of the TC model is not

known. Moreover, the wide diversity of programs raises questions about

the general effectiveness of the TC modality and underscores the need for

defining the essential elements of the TC model and method.

Illumination of the treatment process is essential to improving TC

treatment. The absence of treatment process information has weakened

conclusions concerning the effectiveness of TCs and has obscured efforts

to improve treatment. If links cannot be explicitly established between

program interventions, the course of client change, and eventual

outcomes, the effectiveness of any TC-oriented model remains unclear,

much less proven. Modification of existing TC protocols must be guided

by an understanding of the relevance and timing of particular program

components for different individuals. Knowing why and how individuals

change in TCs is a prerequisite for introducing changes in treatment in

order to increase retention and favorable outcomes.

This chapter provides a framework for a general theory and model of

therapeutic communities, which is elaborated more fully in other writings

(De Leon 1991a, 1994 a, in press; De Leon and Rosenthal 1989; De Leon

and Ziegenfuss 1986). The formulation presented has evolved from the

research and clinical experience obtained in the long-term residential TC,

which is commonly viewed as traditional. This model still serves as the

prototype for the current diversity of TCs and has documented

effectiveness (Anglin and Hser 1991; De Leon 1985; Hubbard et al.

1989; Simpson and Sells 1982).

It should be stressed that the framework presented is not a theory in the

formal sense of a systematic account of how and why people change. It

does not provide operational definitions for the main concepts; there are

no explicit hypotheses, nor are specific cause and effect relationships

postulated. The framework organizes the elements (e.g., perspective,

concepts, assumptions, and program features) used in the TC to

understand itself: These elements are judged to be essential toward

17
characterizing a general model and developing an empirically testable

theory.

The first section of this chapter reviews the TC perspective in terms of its

view of the disorder, the person, right living, and recovery. It describes

the major TC treatment approach, community as method, and the main

program components of a generic TC model. The second section

formulates a framework of the treatment process in the TC in terms of

program interventions, the dimensions of individual change, and the

stages of change. A paradigm is outlined that incorporates behavioral

and social learning principles with perceptions and experiences as

mechanisms toward clarifying the change process. The final section

offers some implications of the theoretical framework for research in

the TC.

THE TC PERSPECTIVE, APPROACH, AND PROGRAM

COMPONENTS

The TC can be distinguished from other major drug treatment modalities

in two fundamental ways. First, the TC offers a systematic treatment

approach that is guided by an explicit perspective on the drug use

disorder, the person, recovery, and right living. Second, the primary

therapist and teacher in the TC is the community itself, which consists of

the social environment, peers, and staff members who, as role models of

successful personal change, serve as guides in the recovery process.

Thus, the community is both the context in which change occurs and the

method for facilitating change.1

View of the Disorder

Drug abuse is regarded as a disorder of the whole person. Although

individuals differ in their choice of substances, abuse involves some or all

of the areas of functioning. Cognitive, behavioral, and mood

disturbances appear, as do medical problems; thinking may be unrealistic

or disorganized; and values are confused, nonexistent, or antisocial.

Frequently there are deficits in verbal, reading, writing, and marketable

skills. Finally, whether couched in existential or psychological terms,

moral issues are apparent.

Abuse of any substance is seen as behavior with multiple determinants.

Physiological dependency is secondary to the wide range of

18
circumstances that influence and then gain control over an individual’s

drug-use behavior. Invariably, problems and situations that are

associated with discomfort become regular signals for resorting to drug

use. For some abusers, physiological factors may be important, but for

many these remain minor relative to the behavioral deficits that

accumulate with continued substance abuse. Physical addiction or

dependency must be seen in the wider context of the individual’s

psychological status and lifestyle. Thus, the problem is the person, not

the drug. Addiction is a symptom, not the essence of the disorder. In the

TC, chemical detoxification is a condition of entry, not a goal of

treatment. Rehabilitation focuses on maintaining a drug-free existence.

View of the Person

Rather than drug-use patterns, individuals are distinguished along

dimensions of psychological dysfunction and social deficits. A

considerable number of clients never have acquired conventional

lifestyles. Vocational and educational deficits are marked; mainstream

values either are missing or unpursued. Most often, these clients emerge

from a socially disadvantaged sector where drug abuse is more a social

response than a psychological disturbance. Their TC experience can be

termed habilitation—the development of a socially productive,

conventional lifestyle for the first time in their lives.

Among clients from advantaged backgrounds, drug abuse is more directly

expressive of psychopathology, personality disturbance, or existential

malaise. For these clients, the term rehabilitation is more suitable

because it emphasizes a return to a lifestyle previously lived, known, and

perhaps rejected.

Regardless of social class differences, substance abusers share important

similarities. All reveal some problems in socialization, cognitive/

emotional skills, and overall psychological development, which is evident

in their immaturity, poor self-esteem, conduct and character disorders, or

antisocial characteristics. Typical features include low tolerance for all

forms of discomfort and delay of gratification; inability to manage

feelings (particularly hostility, guilt, and anxiety); poor impulse control

(particularly sexual or aggressive); poor judgment and reality testing

concerning consequences of actions; unrealistic self-appraisal in terms of

a discrepancy between personal resources and aspirations; prominence of

lying, manipulation, and deception as coping behaviors; and problems

with authority and personal and social irresponsibility (i.e., inconsistency

19
or failures in completing expected obligations and persistent difficulties

in managing guilt). Additionally, significant numbers have marked

deficits in education and marketable communication skills.

These clinical characteristics do not necessarily depict an “addictive

personality,” although many of these features are diagnostic of conduct

disorder in the younger substance abuser, which often evolves into adult

character disorder. Nevertheless, whether antecedent or consequent to

serious drug involvement, these characteristics are observed to be

correlated with chemical dependency. More importantly, TCs require a

positive change in these characteristics as essential for stable recovery.

Thus, all clients in TC-oriented treatment follow the same regime.

Individual differences are recognized in specific treatment plans that

modify the steps, not the course, of the client’s experience in the TC.

View of Right Living

TCs adhere to certain precepts and values as essential to self-help

recovery, social learning, personal growth, and healthy living. Some

precepts specifically orient the individual to the priority and meaning of

self-help recovery. For example, they stress the personal present (here

and now) as opposed to the historical past (then and when). Past

behavior and circumstances are explored only to illustrate the current

patterns of dysfunctional behavior, negative attitudes, and outlook.

Individuals are encouraged and trained to assume personal responsibility

for their present reality and their future destiny.

The view of right living also emphasizes explicit values that guide how

individuals relate to themselves, peers, significant others, and the larger

society. These include truth and honesty (in word and deed), the work

ethic, learning to learn, personal accountability, economic self-reliance,

responsible concern for peers, family responsibility, community

involvement, and good citizenry.

The ideological and psychological views of the TC perspective are

integrated into its teachings and methods to achieve specific social and

psychological goals. For example, the requirement of truth and honesty

in all matters counters the manipulation and deceitful character features of

many substance abusers; the values of accountability and social

responsibility are integral teachings in training and socialization.

Acquiring vocational or educational skills and social productivity can be

motivated by the values of achievement and self-reliance; healthy

20
behavioral alternatives to drug use are reinforced by a commitment to the

values of abstinence. In general, sobriety is a prerequisite for learning to

live right, but right living is required to maintain sobriety.

View of Recovery

The aims of treatment are global in the TC. The primary psychological

goal is to change the negative patterns of behavior, thinking, and feeling

that predispose drug use; the main social goal is to develop a responsible,

drug-free lifestyle. Stable recovery, however, depends on a successful

integration of these social and psychological goals. Behavioral change is

unstable without insight, and insight is insufficient without experience.

Thus, conduct, emotions, skills, attitudes, and values must be integrated

to ensure enduring lifestyle changes and a positive personal social

identity. The social and psychological goals of the TC shape its treatment

regime as well as define several broad assumptions concerning its view of

recovery.

Recovery is a Developmental Process. Change in the TC can be

understood as a passage through stages of incremental learning. The

learning that occurs at each stage facilitates change at the next, and each

change reflects movement toward the goals of recovery.

Motivation. Recovery depends on both positive and negative pressures

to change. Some clients seek help, driven by stressful external pressures;

others are moved by more intrinsic factors. For all, however, remaining

in treatment requires continued motivation to change. Thus, elements of

the rehabilitation approach are designed to sustain motivation or detect

early signs of premature termination. Although the influence of treatment

depends on the individual’s motivation and readiness, change does not

occur in a vacuum. Rehabilitation unfolds as an interaction between the

client and the therapeutic environment.

Self-Help and Mutual Self-Help. Treatment is not provided but made

available to the individual in the TC environment through its staff and

peers and the daily regime of work, groups, meetings, seminars, and

recreation. However, the effectiveness of these elements is dependent

upon the individual, who must fully engage in the treatment regime.

Self-help recovery means that the individual makes the main contribution

to the change process. Mutual self-help also emphasizes the fact that

each individual in the process contributes to the change in others. The

main messages of recovery, personal growth, and right living are

21
mediated by peers through confrontation and sharing in groups, by

functioning as role models, and as supportive friends in daily interactions.

Social Learning. Negative behavioral patterns, attitudes, and

dysfunctional roles were not acquired in isolation, nor can they be

changed in isolation. Therefore, recovery depends not only on what has

been learned but on how, where, and with whom learning occurs.

This assumption is the basis for the community itself serving as healer

and teacher. Learning occurs by doing and participating as a community

member; a socially responsible role is acquired by acting the role. Thus,

changes in lifestyle and identity are gradually learned through

participating in the varied roles of community life, supported by the

people and relationships involved in the learning process. Without these

relationships, new ways of coping are threatened by isolation and the

potential for relapse. Thus, a perspective on self, society, and a life

philosophy must be affirmed by a network of similar others to ensure a

stable recovery.

The TC Approach: Community as Method

The quintessential element of the TC is community. What distinguishes

the TC from other treatment approaches (and other communities) is the

purposive use of the community as the primary method for facilitating

social and psychological change in individuals.2

Community as method means integrating people and practices under a

common perspective and purpose to teach individuals to use the

community to learn about and change themselves. Thus, all TC activities

are designed to produce therapeutic and educational change in the

participants, and all participants are mediators of these therapeutic and

educational changes. The following specific features are distinctive to the

community-as-method model.

Use of Participant Roles. Individuals contribute directly to all

activities of the daily life in the TC, which provides learning

opportunities through engaging in a variety of social roles (e.g., peer,

friend, coordinator, and tutor). Thus, individuals are active participants

in the process of changing themselves and others.

Use of Membership Feedback. The primary source of instruction and

support for individual change is the TC membership. Providing

22
observations and authentic reactions to the individual is the shared

responsibility of all participants.

Use of the Membership as Role Models. Each participant strives to

be a role model of the change process. Along with their responsibility to

provide feedback to others regarding what they must change, members

also must provide examples of how they can change.

Use of Collective Formats for Guiding Individual Change. The

individual engages in the process of change primarily with his or her

peers. Educational, training, and therapeutic activities occur in groups,

meetings, seminars, job functions, and recreation. Thus, the learning and

healing experiences that are essential to recovery and personal growth

unfold in a social context and through social intercourse.

Use of Shared Norms and Values. Rules, regulations, and social

norms protect both the physical and psychological safety of the

community. However, there are beliefs and values that serve as explicit

guidelines for self-help recovery and right living. These guidelines are

expressed in the vernacular and the culture of each TC and are mutually

reinforced by the membership.

Use of Structure and Systems. The organization of tasks (e.g., the

varied job functions, chores, and management roles) needed to maintain

the daily operations of the facility is a main vehicle for teaching selfdevelopment. Learning occurs not only through specific skills training

but in adhering to the orderliness of procedures and systems, in accepting

and respecting supervision, and in behaving as a responsible member of

the community upon whom others are dependent.

Use of Open Communication. The public nature of shared

experiences in the TC is used for therapeutic purposes. The private inner

life, feelings, and thoughts of the individual are matters of importance to

the recovery and change process, not only for the individual but for other

members. Thus, all personal disclosure eventually is shared.

Use of Relationships. Friendships with particular individuals, peers,

and staff are essential to encourage the individual to engage and remain in

the change process. The relationships developed in treatment are the

basis for the social network needed to sustain recovery beyond treatment.

23
The Generic TC Model: Basic Components

The TC perspective on the disorder, the person, recovery, and right living

and its distinctive approach, the use of community as method, provide the

conceptual basis for defining a generic TC program model in terms of its

basic components. These components are adapted in different ways and

in various settings, both residential and nonresidential.

Community Separateness. TC-oriented programs have their own

names, often innovated by the clients, and are housed in a space or locale

that is separate from other agency or institutional programs or units and

from the drug-related environment. In the residential settings, clients

remain away from outside influences 24 hours a day for several months

before earning day-out privileges. In the nonresidential “day treatment”

settings, the individual is in the TC environment for 4 to 8 hours and then

is monitored by peers and family. Even in the least restrictive outpatient

settings, TC-oriented programs and components are in place. Clients

gradually detach from old networks and relate to drug-free peers in the

program.

A Community Environment. The inner environment of a TC facility

contains communal space to promote a sense of commonality and

collective activities (e.g., groups, meetings). The walls display signs that

state the philosophy of the program-the messages of right living and

recovery. Corkboards and blackboards identify all participants by name,

seniority level, and job function in the program, and daily schedules are

posted. These visuals display an organizational picture of the program

that the individual can relate to and comprehend, which promotes

affiliation.

Community Activities. Treatment or educational services must be

provided within a context of the peer community to be effective. Thus,

with the exception of individual counseling, all activities are programmed

in collective formats. These activities include at least one daily meal

prepared, served, and shared by all members; a daily schedule of groups,

meetings and seminars, team job functions, and organized recreational

and leisure time; and ceremonies and rituals (e.g., birthdays and

phase/progress graduations).

Staff Roles and functions. The staff members are a mix of recovered

professionals and other traditional (e.g., medical, legal, mental health, and

educational) professionals who must be integrated through cross-training

24
that is grounded in the basic concepts of the TC perspective and

community approach. Professional skills define the function of

individual staff (e.g., nurse, physician, lawyer, teacher, administrator,

case worker, or clinical counselor). Regardless of professional discipline

or function, however, the generic role of all staff is that of community

members who are rational authorities, facilitators, and guides in the

self-help community method.

Peers as Role Models. Clients who demonstrate the expected

behaviors and reflect the values and teachings of the community are

viewed as role models. Indeed, the strength of the community as a

context for social learning relates to the number and quality of its role

models. All members of the community are expected to be role

models—roommates; older and younger residents; and junior, senior, and

directorial staff. TCs require these multiple role models to maintain the

integrity of the community and to ensure the spread of social learning

effects.

A Structured Day. The structure of the program relates to the TC

perspective, particularly the view of the client and recovery. Ordered,

routine activities counter the characteristically disordered lives of these

clients and distract them from negative thinking and boredom, which can

predispose drug use. Structured community activities also facilitate the

learning of self-structure for the individual in time management,

planning, setting and meeting goals, and general accountability. Thus,

regardless of its length, each day has a formal schedule of varied

therapeutic and educational activities with prescribed formats, fixed

times, and routine procedures.

Phase Format. The treatment protocol, or plan of therapeutic and

educational activities, is organized into phases that reflect a

developmental view of the change process. The emphasis is on

incremental learning at each phase, which moves the individual to the

next stage of recovery.

Work as Therapy and Education. Consistent with the TC’s self-help

approach, all clients are responsible for the daily management of the

facility (e.g., cleaning activities, meal preparation and service,

maintenance, purchasing, security, coordinating schedules, and

preparatory chores for groups, meetings, seminars, and activities). In the

TC, the various work roles mediate the essential educational and

therapeutic effects. Job functions strengthen affiliation with the program

25
through participation, provide opportunities for skills development, and

foster self-examination and personal growth through performance

challenge and program responsibility. The scope and depth of client

work functions depend upon the program setting (e.g., institutional versus

free-standing facilities) and client resources (level of psychological

function and social and life skills).

TC Concepts. There is an organized curriculum for teaching the TC

perspective, particularly its self-help recovery concepts and view of right

living. The concepts, messages, and lessons of the curriculum are

repeated in the various groups, meetings, seminars, and peer

conversations as well as in readings, signs, and personal writings.

Peer Encounter Groups. The main therapeutic group is the encounter

group, although other forms of therapeutic, educational, and support

groups are utilized as needed. The minimal objective of the peer

encounter group is similar in TC-oriented programs—to heighten

individual awareness of specific attitudes or behavioral patterns that

should be modified. However, the encounter process may differ in the

degree of staff direction and intensity, depending on the client subgroups

(e.g., adolescents, prison inmates, or the dually disordered).

Awareness Training. All therapeutic and educational interventions

involve raising the individual’s consciousness of the impact of his or her

conduct and attitudes on themself and the social environment and

conversely the impact of the behaviors and attitudes of others on themself

and the social environment.

Emotional Growth Training. Achieving the goals of personal growth

and socialization involves teaching individuals how to identify feelings,

express feelings appropriately, and manage feelings constructively

through the interpersonal and social demands of communal life.

Planned Duration of Treatment. The optimal length of time for full

program involvement must be consistent with the TC’s goals of recovery

and its developmental view of the change process. How long the

individual must be in the program depends on their phase of recovery,

although a minimum period of intensive involvement is required to

ensure internalization of the TC teachings.

Continuity of Cafe. Completion of primary treatment is a stage in the

recovery process, and aftercare services are an essential component in the

26
TC model. Whether implemented within the boundaries of the main

program or separately as in special halfway houses, the perspective and

approach guiding aftercare programming must be continuous with that of

primary treatment in the TC. Thus, the views of right living and self-help

recovery and the use of a peer network are essential to the appropriate use

of vocational, educational, mental health, social, and other typical

aftercare or reentry services.

The use of community as method assumes that individual receptivity and

willingness to learn and change is fostered by an affiliation with others

engaged in a similar struggle to change (De Leon 1991a). Thus, the basic

components in TC-oriented programs focus upon strengthening the

perception of community among all participants, staff, and clients.

However, creating and sustaining the perception of community is a

constant challenge for the TC-oriented programs that serve a wide

diversity of populations in various settings. Thus, the range and

implementation of the basic TC components are flexible and reflect the

need for constant innovation.

THE TREATMENT PROCESS IN THE TC

A framework for understanding the process of change in the TC reflects

its perspective, approach, and model. A disorder of the whole person

means that change is multidimensional. Thus, change must be viewed

along several dimensions of behavior, perceptions, and experiences. The

main approach for facilitating change is the use of the community as

method, which consists of multiple interventions. Recovery unfolds as

developmental learning, which can be described in terms of characteristic

stages of change. The following section outlines the main elements of a

process framework as well as the interventions, dimensions, perceptions,

experiences, and stages of change.

Interventions

In the TC, all activities are designed to produce therapeutic and educative

effects. These activities, singly and in various combinations, constitute

interventions that directly and indirectly impact the individual in the

change process. Indeed, it is this element of using every activity for

teaching or healing that illustrates the meaning of community as method.

Illuminating the complexity of TC interventions can be approached

through a classification of the range of activities and a description of their

27
characteristics. The diverse community activities that are basic to the TC

model can be organized into three main classes of interventions:

therapeutic and educative effects, community and clinical management,

and community enhancement.

Therapeutic and Educative Effects. These activities consist of various

group formats as well as individual counseling. They promote the

expression of emotions, divert negative acting out, permit ventilation of

feeling, resolve personal and social issues, increase communication and

interpersonal skills, examine and confront behavior and attitudes, and

offer instruction in alternate modes of behavior. The main groups are

encounters, probes, tutorials, and marathons. These activities are

amplified by special theme groups that focus on issues related to

ethnicity, gender, and age.

Community and Clinical Management. These activities maintain the

physical and psychological safety of the environment and ensure that

resident life is orderly and productive. They protect the community as a

whole and strengthen it as a context for social learning. The main

activities/interventions are privileges, disciplinary sanctions, house

surveillance (house run), and urine testing.

Community Enhancement. These activities facilitate the individual’s

assimilation into the community and strengthen their perception of

community and therefore its capability to teach and to heal. They include

the four main facilitywide meetings: the morning meeting; seminars; the

house meeting held each day; and the general meeting, which is called

when needed. Ceremony and rituals also are regular facilitywide events

that enhance community. These include deaths, birthdays, phase/progress

landmarks, and program and school graduations. Finally, certain national

and ethnic/cultural holidays are celebrated by all members with seminars,

special meals, music, and plays.

Additional Activities and Interventions. These consist of a variety of

activities that are not distinctive to the TC model, although they are

ancillary or supplemental to the community interventions. They include

relapse prevention training; special skills groups such as parenting;

various academic, social, and educational groups; and vocational and life

skills training groups.

Characteristics of Interventions. All TC activities constitute

interventions that are delivered by different people in various settings.

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How, where, and for whom these interventions are delivered can be

organized in terms of the following broad characteristics: interactive,

formal and informal, community, and individually oriented.3

Interactive Interventions. The impact of particular interventions may

be enhanced, delayed, or moderated in their interaction with other

activities. For example, the messages delivered in seminars may be

clarified by informal peer conversations preceding and following the

seminars, or an individual’s acceptance of the observation made in the

encounter group may not occur until he or she observes and confronts the

same behavior in another member in a later encounter group. Thus,

separate and various combinations of activities are required for some

duration, intensity, and frequency to produce individual change.

Formal and Informal Interventions. Activities may be planned or

unplanned, occur in designated or arbitrary settings, and be mediated by

staff or residents. Typical planned activities are the scheduled groups and

meetings and one-to-one counseling sessions conducted by staff or by

residents under staff supervision. Many interventions are unplanned and

informally mediated in the daily peer interactions. Residents are expected

to monitor and instruct other residents in matters of security, rules,

regulations, role model expectations, social manners, and civility.

Finally, personal disclosures and mutual sharing are spontaneous and

constantly occurring interventional activities.

General Community Interventions. Although all interventions are

intended to change the individual, some may be delivered directly to the

person and others indirectly to the community. General community

interventions comprise the schedule of planned activities, including

meetings, groups, seminars, job functions, and community meals directed

to the general membership. They are not contingent upon any specific

event or problem in the community, and their impact depends on the

daily participation of the membership.

Specific Community Interventions. These interventions are not

routinely scheduled; they are specifically dependent upon community

needs. For example, community “pull-ups” (corrective reminders to the

membership), house bans, general meetings, special recreational events,

and communitywide retreats are implemented to address specific issues of

the general membership, such as problems to be corrected and needs for

inspiration or affirmation. These specific interventions may be signaled

by actual or anticipated events or problems in the general community,

29
such as unexpected dropouts, violence, drug use, poor participation, or

low morale.

Specific Individual Interventions. Certain interventions are specifically

contingent upon the individual’s behavior. These may be delivered by

peers as pull-ups, confrontations, affirmations, suggestions, or

instructions that occur both in and outside the clinical groups. They also

may be delivered by staff as privileges, job changes, phase changes, oneon-one brief or extended counseling sessions, verbal reprimands, or

various disciplinary sanctions.

Although interventions may be targeted to specific individuals, they are

delivered in a community context. For example, disciplinary

consequences that are devised and implemented by staff are informed by

the observations of peers. Peer involvement elevates both the incident

and the corrective intervention to a communitywide teaching. In this

way, the individual, the peers, and the general membership are

collectively accountable for the conduct of the community.

Dimensions of Change

Partitioning the individual into separate dimensions is a somewhat

artificial device that is analogous to attempts at classification of the TC

milieu into separate interventions. Thus, a complete description of

change in the whole person includes both the objective behavioral

dimensions as well as subjective changes reflected in self-perceptions and

experiences. These are discussed separately for purposes of clarity.4

Behavioral change can be described along four broad dimensions that

reflect the TC perspective. The dimensions of community member and

socialization refer to the social development of the individual,

specifically as a member in the TC community and generally as a

prosocial participant in the larger society. The developmental and

psychological dimensions refer to the evolution of the individual as a

unique person in terms of their basic psychological function, personal

growth, and identity. Each dimension refers to the same individual from

different aspects in terms of observable behavioral indicators.

Community Member. This dimension refers to the evolution of the

individual as a member in the TC community. It can be described in two

related domains—affiliation and role model. The behavioral indicators in

these domains reflect how much the individual utilizes the community as

30
method and how well they exhibit the behavioral expectations of the

community. Those members who are affiliated understand the TC

perspective and the philosophy of the program, and they transmit and

illustrate the concepts of recovery and right living.

Socialization. This dimension refers to the evolution of the individual as

a prosocial member of the larger society. It can be described in three

related domains—social deviancy, habilitation, and right living. The

behavioral indicators in these domains reflect the individual’s repertoire

of mainstream social skills, attitudes, and values. For most clients in

TCs, a prosocial lifestyle has been rejected, was never acquired, or has

eroded with continued drug use. Thus, life in the TC permits the

acquisition or reacquisition of a socialized lifestyle.

Developmental. This dimension refers to the evolution of individuals in

terms of their personal growth. It can be described in two related

domains—maturity and responsibility. The behavioral indicators in these

domains center on self-regulation (e.g., impulses and delaying

gratification); social management (in relations with staff/authorities,

peers, and the community); and consistency in meeting obligations to self

and others.

Psychological. This dimension refers to the basic cognitive and

emotional skills that underlie change in the other dimensions. The

behavioral indicators of these skills are grouped under two

domains—cognitive skills (i.e., awareness, judgment, insight, reality, and

decisionmaking) and emotional skills (i.e., communication and

management of feeling states). Without improvement in faulty cognitive

and emotional skills, affiliation as a community member, enduring

change in socialization, and developmental maturity are not possible. A

third psychological domain consists of typical signs or symptoms of

emotional and mental disturbance.

Characteristics of the Dimensions

Change or improvement in all of the previously discussed dimensions

must occur to ensure a stable recovery. There are characteristics,

however, that underscore the complexity of individual differences and the

dynamic nature of the change process itself. These can be summarized as

interrelated, interactive, variable, asymmetrical, and individualized

dimensions.

31
Interrelated. The domains of each dimension share common behavioral

indicators. For example, some indicators of role modeling may be the

same as those of maturity, and some maturity indicators are those of

socialization. However, it is the organization of the indicators that

defines the domains and distinctions across the dimensions.

Interactive. The dimensions may be mutually influential. For example,

changes in community membership (e.g., role modeling) may facilitate

those in the developmental dimension (e.g., maturity). Also, increased

awareness, a basic skill in the psychological dimension, is a prerequisite

for changes in all other dimensions.

Variable. Within a domain, not all behaviors change at the same rate. In

the domain of maturity, for example, the resident may show a reduction

in cursing but continue to talk back to staff. Within the psychological

domain, awareness may be raised concerning the consequences of

negative behavior before the behavior itself changes.

Asymmetrical. Across domains and dimensions, the rate of change is

not necessarily correlated. For example, the resident may improve in role

modeling more quickly than in maturity.

Individualized. Individual differences are the rule with respect to change

on any dimension. Not all residents start at the same place on the

dimension, nor do they progress in a uniform way. Although members

are expected to arrive at certain points in the treatment process, individual

rates of change vary. These differences can be accommodated within

limits if the program focuses on the fact of change rather than on the

magnitude of change and on the individual’s willingness to continue in

the process.

Essential Perceptions and Experiences

Although the TC is behaviorally oriented, the process of change is

understood by the participants in subjective terms, perceptions, and

experiences. Individuals not only actively engage in the behaviors and

attitudes to be changed, they must feel the feelings associated with this

engagement, understand the meaning or value of the change, and come to

see themselves, others, and the world differently. Perceptions and

experience are viewed as subjective aspects of behavioral change.

Although they may be considered as dimensions or domains, they are

32
described separately for purposes of illuminating their distinctive

contribution to the process.

As ongoing events, perceptions and experiences can be defined on a

moment-to-moment basis leading to an endless listing of such events.

The qualifier terms essential and critical underscore those particular

perceptions and experiences that staff, residents, and observers agree are

necessary for the individual to remain in and benefit from the treatment

process.

Classification of Essential Perceptions

Although community life in the TC contains an omnipresent message to

“stay the course,” residents constantly struggle to remain in the treatment

situation. How they perceive their problems, progress, peers, staff, the

program environment, treatment demands, and outside influences

demands contemplation to continue in the process, almost on a daily

basis. These perceptions can be grouped under the following themes:

circumstances, motivation, readiness, and suitability.

Circumstances. A number of life situations and conditions can drive

people to seek treatment in TCs. They display fears and worries

concerning legal, fiscal, health, family, social, domestic, and employment

problems. Typically, individuals report explicit fears of jail or the court

process, injury, violence, drug overdose, illness, or death. Other fears

and anxieties are associated with actual or anticipated losses (such as

employment, school, family, and relationships) or of simply being

homeless and destitute. Although these various conditions differ across

individuals and may change over time for the same individual, they are

all perceived as some form of external pressure that compels the

individual to seek admission to, remain in, or leave the treatment

situation.

Motivation. In contrast with perceptions of external conditions,

individuals are motivated or moved to seek and remain in treatment by

various inner reasons for personal change. These reasons are based on

both positive and negative perceptions of themselves and their life

options. Typically, positive perceptions are expressed in terms of selfefficacy, possibilities, desire for a new lifestyle and to attain the good

things in life, or for personal growth or better social and family

relationships. Negative perceptions are expressed in more selfdeprecating terms, such as desire to abate or eliminate feelings of guilt,

33
self-hatred, or personal despair based on hurting and failing themselves or

others. Intrinsically motivated individuals come to perceive that they are

the problem, rather than the drugs or their life circumstances, and they

learn to accept that they must change, not the world around them.

Readiness. Individuals who come to TCs may be motivated to change,

but many have not accepted the necessity for treatment. Those who are

ready for treatment have rejected all other options for change; that is,

they perceive treatment as their only alternative. Motivated individuals

who are not specifically ready to engage in the treatment process may

perceive nontreatment alternatives as viable, such as managing their own

problems through self-control; making situational changes in

employment, relationships, or geographic location; or getting help and

support from religion, family, or friends.

Suitability. Residents in the TC may be motivated and ready for

treatment but do not perceive the TC as appropriate for their needs. Thus,

suitability is the self-perceived match between the individual and TC

treatment. Suitability for treatment in the TC is indicated by the

resident’s acceptance of the TC approach: its goals, philosophy, and

teachings (e.g., commitment to a drug-free lifestyle involving changes in

behavior, attitudes, and values of right living); its daily regime (e.g.,

community living, lack of privacy, privileges and sanctions, and rules and

regulations); its social learning methods (work as education and therapy,

peer interaction, group participation, and personal disclosure) and its

long-term time commitment (interrupting one’s life during the residential

treatment period).

Characteristics of the Essential Perceptions

The characteristics of the four classes of perception are similar to the

dimensions of change in that they are interrelated or interdependent. For

example, readiness for treatment cannot occur without motivation, and

suitability for a particular treatment such as the TC is unlikely in an

individual who is not ready to engage in any treatment.

Extrinsic circumstances or pressures often induce or clarify intrinsic

motivation. For example, repeated problems with the law, health,

employment, and social and family relationships eventually lead many

individuals to acknowledge their problems with drugs and their need to

change themselves. However, although extrinsic pressures may bring the

74
individual to treatment, it is intrinsic motivation that sustains continued

participation in the process.

A third characteristic of these perceptions is their changeability. Shifts in

motivation, readiness, and suitability can occur daily. Residents

continually make decisions concerning their reasons for treatment and

their needs for a long-term residential program. These shifts reflect the

attractions and pressures from outside the program, such as friends,

family, social, and employment circumstances. They also relate to the

influences inherent in residential life, such as positive and negative

interactions with peers and staff, program demands, and boredom with

the daily regime.

Treatment progress also can have unpredictable effects on motivation,

readiness, and suitability. Rapid improvement in the early days of

treatment, for example, could result in premature dropout. Paradoxically,

a transient sense of well-being could lessen motivation or readiness to

continue in treatment (“flight into health”). The resident may stop feeling

bad, conclude that he or she can handle their problem on their own, and

no longer perceives the necessity for treatment. Conversely, delayed or

slow improvement may lead to demoralization, weaken readiness to

continue, and result in early dropout, particularly in individuals who

cannot delay gratification.

Ironically, important changes in perceived suitability for the TC occur

after individuals actually encounter the demands of the community

environment. For example, they may see themselves as different from

others in terms of their drug use or their cultural and social background,

or they may view the program negatively and its demands as too harsh or

lacking in sufficient personal attention. Such perceptions of mismatch

between the individual’s needs and the program’s approach can lead to

premature dropout.

Much of the effort in TC programs is aimed at monitoring and modifying

these perceptions, which shift continually throughout the resident’s tenure

in residence. Peers and staff attempt to sustain the individual’s

motivation and reaffirm the suitability of the TC by helping the

individual reassess and minimize the importance of outside influences, by

reminding them of the gains made and the problems that still need to be

addressed, and why he or she needs to be in the TC.

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Critical Perceptions

Certain self-perceptions appear to be critical in the change process. These

are reported as a distinct awareness of positive self-change in contrast

with past self-perceptions. These contrasts simply may be residents

seeing themselves as behaving, thinking, and feeling differently, usually

in statements of self-efficacy and self-esteem. More dramatic contrasts

may be a self-perceived change in identity, expressed in terms of being

oneself, being real, or not being the person they once were.

Perceptual contrasts may occur in encounter groups or marathons as an

element in the high-impact critical experience (i.e., therapeutic events

referred to earlier). They also may arise in other special circumstances

away from the program, such as day trips or weekend furloughs. These

situations provide the individual with explicit opportunities for making

comparative observations and confirming personal changes with respect

to how they experience the old neighborhood, the proximity of drugs and

users, or how they relate to friends, family, and children.

More often, the cues for contrasts are ordinary, emerging in the various

roles and everyday activities of the community (e.g., seeing younger or

newer residents who are earlier in the process, listening to a seminar,

handling a stressful or provocative situation with peers or staff in a new

constructive way, managing feelings differently, or simply noting the

absence or reduced frequency of old thinking about drugs and related

matters).

Although they are distinctive, contrasts usually represent the summation

of smaller unperceived changes in behaviors, thinking, and feelings

(i.e., “kindling”), which finally culminate in the individual’s clear

recognition and acceptance of self-change. Regardless of how and when

they occur, however, perceptual contrasts are integral to the TC process.

Behavioral and cognitive change is unstable if residents cannot

discriminate; that is, perceive and authentically acknowledge where they

were, where they are, and where they want to be.

Classification of Essential Experiences

As with perceptions, a limited array of experiences are underscored which

appear as necessary to the change process within the TC. These can be

conceptualized under three themes—healing experiences, subjective

learning experiences, and critical experiences as therapeutic events.

36
Healing Experiences. Healing refers to palliating or lessening feelings

of emotional pain in its various forms. Fears, anger, guilt, hurt,

confusion, despair, desperation, hopelessness, and aloneness are some of

the pains common to residents in TCs. These are associated with specific

circumstantial stress, pressures, and threats as well as longer term

psychological injuries and personal and social isolation. The healing

experiences can be organized under several themes that reflect the TC

perspective: nurturance-sustenance, physical and psychological safety,

and social relatedness.

Nurturance-Sustenance. These experiences include the basic

provisions of daily maintenance: three meals, housing, clothing,

cosmetic accessories, medical, dental, and social and legal advocacy

services. These provisions are entitlements rather than privileges for

which nothing is asked of the client except that they participate in the

treatment regime. The nurturant experiences are primarily those of relief

from circumstantial pressures, distress, and uncertainties.

Physical Safety. For those who have characteristically lived with fears

and anxieties associated with their drug abuse lifestyle, street life,

domestic violence, and sexual and interpersonal abuse, physical safety

provides an essential healing experience. The TC community maintains

strict adherence to cardinal rules against violence, threats of violence,

stealing, sexual abuse and harassment, and drug or alcohol use. The

security of the facility with respect to daily traffic and unauthorized

intrusion is steadfastly maintained. Moreover, maintenance of the rules

governing personal security is the responsibility of the residents as well as

the staff. Thus, the code of the TC is collective security, which provides

relief from common fears and anxieties associated with physical safety.

Psychological Safety. Although many individuals in TCs have lived

precariously, rebelliously, or antisocially, they are psychologically fearful

of facing themselves, other people, the demands of ordinary living, and of

change itself. Facing these fears requires trusting others to support their

psychological risk-taking. For most residents in the TC, the dissolution

of mistrust is a profound healing experience that relieves covert, but longstanding intrapersonal and interpersonal fears. The essential experiences

reflecting psychological safety are blind faith, trust, being understood,

and being accepted by others.

Social Relatedness. The past social relationships of residents in TCs

often are characterized by personal isolation or attachments with others

37
that are unhealthy or frankly self-destructive. Family histories tend to be

marked by disturbance, abuse, and deprivation. Even among those from

socially advantaged backgrounds and intact families, their loss of selfcontrol and disordered lifestyle have alienated them from significant

others. For many this alienation precedes their drug problems and they

have marginal identification with any family or community and no real

friendships. The essential social experiences that reflect their

relationships with others include identification, empathy, and bonding.

Subjective Learning Experiences. Change in the TC occurs through

trial and error learning. This involves behavioral changes followed by

objective consequences (e.g., disciplines or rewards) as well as

experiential or subjective outcomes associated with these consequences.

Typically, these experiences involve self-evaluative perceptions,

thoughts, and feelings. For example, when residents revert to undesirable

behaviors leading to disciplinary actions and social disapproval,

experiential consequences may occur on the theme of self-rejection

(e.g., disappointment, worthlessness, failure, and guilt). When they

engage in effective behaviors, positive subjective outcomes may occur on

the theme of self-efficacy (e.g., confidence, satisfaction, mastery, and selfesteem).

When residents feel, as well as think about the effects of consequences,

learning (or unlearning) is more stable. For example, the positive

socialization rewards of privileges, job promotions, and peer recognition

occur only if residents experience them as positive events. Similarly,

disciplines, demotions, or bans are effective teaching consequences if

they are experienced in a negative way by the resident. Subjective

outcomes are viewed as essential in the change process, specifically for

achieving internalized learning; that is, behavior change that is

maintained by fewer external consequences and more self-control.

Critical Experiences as Therapeutic Events

The change process is erratic, gradual, and incremental. However, the

course is punctuated by distinctive moments of individual change that

involve a total or critical experience involving related thoughts,

perceptions, feelings, and understanding. Critical experiences mark

therapeutic events because they are remembered occurrences that appear

to singularly facilitate individual change in behavior (e.g., effective ways

of coping and responding); insight (e.g., new understanding of the

relationship between self and influences); and commitment (e.g.,

38
redecisions to continue in the process). Conversions, for example, are

special cases of dramatic change that involve one or more therapeutic

events.

Although these experiences appear to be sudden, they usually represent

developing changes up to the point of their occurrence. Occasionally,

however, they occur as isolated incidents of “personal breakthrough.”

These events often are unplanned and spontaneous, although programs

attempt to induce them at appropriate clinical points. For example,

intense group marathons, special retreats, or wilderness activities can

promote dramatic bonding or self-efficacy experiences that can sustain

individuals in the treatment process.

Therapeutic events or moments link previous learning with current

learning, which in turn mediates new learning. For the individual, they

often represent a point of reframing their problems, life options, and selfperceptions. Although they may involve painful feelings, they are

reported as positive experiences that motivate the individual to continue

in the process.

Characteristics of the Essential Experiences

The essential experiences are interdependent and interrelated

characteristics that illuminate how experiences contribute to the change

process. A resident may first experience blind faith before fully

experiencing trust. Without trust, there is no meaningful self-disclosure,

which is the basis for experiencing understanding and acceptance.

There also is an interrelationship between behavioral learning and healing

experiences. Residents who experience trust, understanding, acceptance,

or bonding are more likely to remain in treatment and engage in the

behaviors that lead to the subjective outcomes that facilitate internalized

learning. Moreover, healing experiences are positive subjective outcomes

that directly reinforce the social behaviors that result in these experiences.

For example, residents who personally disclose to others obtain the

positive experience of understanding and acceptance from others, and

they learn that disclosure and similar behaviors evoke these healing

experiences. By displaying understanding and acceptance behavior to

others, they learn to facilitate healing experiences in others. In the argot

of the TC, residents learn how to “reach out” for themselves and “give it

away” to others.

39
A PROCESS PARADIGM: SOME PRINCIPLES AND

MECHANISMS OF CHANGE

Thus far, the main elements of the TC treatment process have been

outlined in terms of the interventions, behavioral dimensions, and

essential perceptions and experiences. This section briefly outlines a

paradigm to illuminate how these elements are linked or related in the

change process, which incorporates behavioral and social learning

principles with essential experiences and perceptions as mechanisms in

the process.

The Learning Principles

Change in the TC is viewed from a behavioral orientation in terms of

learning and training. Attitudes, feelings, roles, and awareness are

regarded as valid behavioral data. For example, a resident’s attitude on

the job or in the morning meeting may evoke various responses in others.

In conversations or groups, this attitude will be explicitly translated into

observable behaviors (e.g., gestural, postural, or verbal) (De Leon

1991 a). Thus, embedded in the community life of the TC are familiar

behavioral training and social learning principles that underlie change in

the four dimensions.

Efficacy Training. The general principle of trial and error learning is the

basis for efficacy training in the TC. The resident must engage in the

behavior that produces the mistakes as well as the correct positive

outcomes. Indeed, errors highlight a subtle distinction between efficacy

and self-efficacy that relates behavioral change with subjective outcomes.

Efficacy is performing the behavior that works; self-efficacy, as a

subjective outcome, is enhanced by overcoming the errors in performing

the behavior that works.

Social Role Training. Although specific behaviors and attitudes are the

primary observations, the focus of training is on constellations of related

behaviors, skills, and attitudes that have labels indicating their social or

psychological relevance. Thus, the resident jobs and positions in the

work hierarchy, such as expediter, department head, and coordinator, are

examples of roles learned in the TC. Socialization is a special type of

role training that refers to classes of social behaviors and attitudes other

than work roles. Typical labels for these behaviors are responsible,

cooperative, and mature; role model behaviors are a broader class of

40
related behaviors and attitudes reflecting the values and expectations of

the community.

Vicarious Learning. Individuals often initiate self-change through

observation of and identification with others in the process of change.

The sources of vicarious learning derive from the context of community

life-its rules, norms, daily regime of activities, and informal

interactions. For example, adherence to the explicit rules that prohibit

drug use and all forms of antisocial behavior is mediated by peers and

staff who act as role models for the appropriate behaviors and attitudes as

normative expectations of the community.

Vicarious cues arise directly from the day-to-day social and interpersonal

interaction with others. Hearing different life stories, witnessing subtle

and dramatic examples of behavior change over time, and experiencing

empathic exchanges with peers transmit covert but powerful emotional

and perceptual signals toward change. Indirect vicarious cues come from

information about others (e.g., the dispositions of dropouts, the successes

of graduates, and the struggles of staff). All vicarious cues initiate some

form of imitation, rehearsal, or trial and error attempts at change without

explicit instruction.

Conmunity as Trainer. Although behavioral and social learning

principles are evident in the TC, these are “naturalistically mediated” as

an inherent characteristic of community as method. An explicit

instruction by the community to the community is that peers and staff are

the observers, monitors, and mediators of the messages of recovery and

right living.

Indeed, the role of community member is a trained and mutually

monitored role. Residents are expected to be attentive to both the

physical and social environment of the facility; to offer specific

instruction, feedback, and support for individual efforts to change; and to

express their concerns or affirmation concerning the status of the

community itself. Staff as community members guide the residents to be

role models and peer trainers, and they monitor the fidelity and impact of

the daily activities as interventions for individuals and the community.

Perceptual and Experiential Mechanisms in the Process

In the TC perspective, changing the whole person involves not only

observable behaviors but subjective perceptions and experiences. The

41
essential and critical perceptions and experiences can be viewed as

integral mechanisms in the process that links interventions with

behavioral change. For example, group acceptance of the individual is an

intervention that induces a healing experience, which encourages the

individual to engage in new behavioral efforts. Such efforts lead to

consequential outcomes—both objective reinforcements (e.g., social

approval, privileges, and change in community status) and subjective

outcomes (e.g., personal efficacy and self-esteem). These changes result

in internalized learning, perceptual contrasts, therapeutic events, and

eventually changes in identity.

The subjective elements in the process may appear gradually in the daily

regime of social interaction or as critical, striking occurrences.

Nevertheless, either as consequences of interventions or correlates of

behavioral change, the essential perceptions and experiences are

necessary to stabilize new learning.

Stages of Change in the TC

Stages and phases are definable points in the developmental process.

These can be described from different but interrelated perspectives of

change, program, and treatment stages. For example, the four dimensions

of change relate to the individual’s movement according to specific goals

or expectations of the program. However, another stage perspective,

treatment process, more closely captures client change in relation to the

treatment activities program. Thus, there are two perspectives of stages

of change—program stages and treatment process stages. However, this

chapter outlines only the program and treatment process stages.6

Program Stages

Three main program stages and several phases within each stage have

been delineated for the traditional long-term TC. These stages are

roughly correlated with time in program as follows: Stage 1, induction,

corresponds to 1 to 60 days; Stage 2, primary treatment, 2 to 12 months;

and Stage 3, reentry, 13 to 24 months. For TCs with shorter durations of

treatments, the length of each stage is shorter, but the goals remain the

same.

In Stage 1, induction, the main goals are assessment and orientation to the

TC. Clinical assessment of the individual continues during the first

2 months of residency to clarify specific treatment needs and overall

42
suitability for the long-term residential TC. The objective of orientation

is to assimilate the individual into the community through full

participation and involvement in all of its activities. Rapid assimilation is

crucial at this point when clients are most ambivalent about the long

tenure of residency. Thus, the new resident is immediately involved in

the daily regime, which emphasizes role induction into the community.

Stage 2, primary treatment, focuses on the main social and psychological

goals of the TC. This stage generally consists of three phases that

roughly correlate with time in program (2 to 4 months, 5 to 8 months, and

9 to 12 months). These phases are defined by the member’s status in the

community (junior, intermediate, or senior resident) and are marked by

plateaus of stable behavior that signal the need for further change. The

daily therapeutic and educative regimen (i.e., meetings, groups, job

functions, and peer and staff counseling) remains the same throughout the

year of primary treatment.

Stage 3, reentry, consists of two phases: early (13 to 18 months) and late

(18 to 24 months) reentry. In the early phase, the main goal is

preparation for healthy separation from the community. Clients continue

to live in the facility but may be attending school or holding full-time

jobs, either within or outside the TC. However, they are expected to

participate in house activities when possible and to carry some

community responsibilities.

In late reentry, the main goal is to complete the separation from TC

residency. Clients are on “live-out” status, involved in full-time jobs or

education and maintain their own households, usually with live-out peers.

They may attend aftercare services such as Alcoholics Anonymous or

Narcotics Anonymous or take part in family or individual therapy. This

phase is viewed as the end of residency but not the end of program

participation.

Stage Interventions. Throughout all the stages, the main social and

psychological goals of the TC are pursued in the daily regime, which

consists of the community and individual interventions previously

described. However, the interventions differ in accordance with stagespecific goals in terms of their frequency, duration, and intensity, and the

use of special groups, meetings, seminars, and professional services. For

example, the specific goals of assimilation and affiliation in the early

stage require less emphasis on therapeutic demands for change and more

emphasis on training and instruction in the TC perspective, approach, and

43
procedures. Similarly, the specific goals of the reentry stage emphasize

acquisition of the skills and information needed for facilitating separation

from the program and transition to independent living. Thus, emphasis is

on individual planning and activities concerning educational and

vocational needs, interpersonal and family relationships, and social and

sexual behavior.

Stage Profiles. Although individual differences are the rule in terms of

rate of change, typical resident profiles can be described for the various

stages and phases of the program. These profiles reflect both the overall

and stage-specific goals of the program in terms of the four dimensions of

change described earlier (i.e., community member, socialization,

developmental, and psychological). These profile descriptions are

illustrated in other writings (De Leon 1994a, 1994b; De Leon and

Rosenthal 1989).

Treatment Stages of Internalization

Progress refers to the movement of the client along dimensions of

behavioral and attitudinal changes with respect to the goals of the

program stages. The treatment process refers to the interaction between

client progress and the myriad of community and individual

interventions. Thus, interaction can be viewed as an evolving

relationship between the individual and the community that can be

described as internalization that is evident in the stability, acceptance,

and use of the behaviors, attitudes, values, and general teachings of

the TC.

For TCs, the importance of internalization is especially salient because

the power of its community method can readily modify observable

behaviors and attitudes in the program setting. However, these changes

may not endure once the individual separates from the omnipresent

influence of the peer community. Practically all residents in TCs display

drug-free behavior during their residential stay; that relapse occurs among

a number of the dropouts and some of the graduates, however,

underscores the relevance of internalization in the change process.

The mark of internalization is the transfer of the influences of new

learning from external (objective) consequences to internal (subjective)

outcome experiences of the individual. Internalized learning can be

characterized as more consistent and more self-initiated (“inner directed”)

than externally influenced learning. Notably, learning that is internalized

44
is generalizable to new situations both inside and outside of the program

(De Leon, in press). In the TC, internalization does not occur all at

once-it evolves over time. This evolution can be characterized in terms

of four stages-compliance, conformity, commitment, and integration.

Compliance. In this stage, there is little evidence of internalization. The

resident adheres to the norms, expectations, and teachings of the

community primarily to avoid negative consequences such as disciplinary

sanctions or undesirable alternatives such as discharge to the street, return

to jail, homelessness, or an unwanted home situation.

Conformity. In this stage, the resident adheres to the program teachings

primarily to maintain affiliation with the community, either to avoid

threats to newly formed relationships or simply to enhance their

acceptance by peers and staff. This stage reflects a high degree of

program affiliation but a relatively low degree of internalization.

Commitment. In this stage, residents adhere to their own personal

resolve to remain in the treatment process and complete the treatment

program. Early phase commitment still reflects a considerable degree of

conformity; the individual’s resolve is largely influenced by the program, 

its goals of completion, graduation, and remaining on parity with peers.

This phase is much like the commitment of college seniors to finish

school with their class, graduate, and receive a degree. However, early

stage commitment also reflects some degree of internalization, since the

social value and psychological importance of completion are major

teachings of the TC. This teaching is incrementally strengthened by the

individual’s experience in attaining the phase and stage goals leading to

program graduation. Thus, residents who commit themselves to

completing the program have internalized a valued program teaching.

In the commitment to self phase, the individual adheres to a personal

resolve to remain in the change process beyond completion of the

program. In this stage, the resident reveals a greater degree of

internalization, since he or she has fully accepted the teaching that

recovery and personal growth are continuing processes.

Integration. This is an evolving stage that begins in treatment but

emerges mainly after separation from the program. The term

“integration” underscores the interrelation between TC influences and

broader life experiences. The values of right living and the recovery

teachings of the program serve as general guidelines and tools for life

45
adjustment. The coping strategies, understanding, and insights of the

previous stages are validated through confirmatory experiences and

generalized to new life situations. Thus, the internalization of TC

teachings is significant and stable. However, individuals gain perspective

on the benefits, limits, and uses of these teachings in their personal

growth or self-actualization.

In this stage, consolidating and advancing personal gains are primary

goals, rather than recovery from chemical dependency. Sobriety

(i.e., abstinence in behavior, thinking, and values) is internalized. The

individual does not consciously think about maintaining abstinence, but

he or she accepts this as a prerequisite for right living. The focus is on

personal growth and psychological and existential issues for which the

individual may utilize therapy or assistance. Their affiliation shifts from

the program community to the wider social community of family, friends,

work, and professional colleagues, and involvements are with mainstream

activities and obligations (e.g., work, education, religion, and social and

family roles).

ldentity Change. A distinctive marker of the integration stage is a

change in identity that is perceived by self and others. No single label

describes how substance abusers view themselves; however, some of the

more frequently stated labels that change during and following treatment

are addict to nonaddict, social deviate to conventional person, baby to

grown up, and antisocial to prosocial citizen. These labels reflect the

general changes in lifestyle as well as the specific behaviors of deviance

and substance use. The shift in identity is gradual since the elements of

identity change are evident throughout all of the stages. However, it is

the powerful mechanism of perceptual contrast that marks the main

change in the integrative stage. Individuals retrospectively reframe and

relabel who they were then and who they are now.

SOME CONSIDERATIONS FOR RESEARCH

The theoretical formulation outlined in this chapter suggests a broad

agenda for research in TCs. The major lines of inquiry are the validity

and utility of the framework itself and the extent to which it is applicable

to the current diversity of TC-oriented programs. This agenda is further

addressed elsewhere in this mongraph. In the final section of this chapter,

some implications for theory, research, and policy in TCs are briefly

considered.

46
Program Models

The extent to which the current diversity of TC-oriented programs is

guided by the perspective and foster community as method is

fundamentally an empirical issue that remains to be evaluated. In this

regard, an initial effort is underway using a modalitywide survey to

describe the range of TC-oriented programs based on many of the

essential elements outlined here (Melnick and De Leon 1993). This

research effort is described briefly in other chapters of this monograph.

Process Framework

Research on treatment process in the TC presents a formidable challenge

for investigators. The framework presented underscores the need for

operational definitions of the elements as well as appropriate measures,

particularly of the perceptual and experiential concepts. Feasible

methods of data collection are needed, as are analytical models for

capturing the effects of interventions in dynamic interaction with a

changing client.

A recent advance in the measurement of essential perceptions has been

the development of a multidimensional instrument assessing

circumstances, motivation, readiness, and suitability (CMRS) for TC

treatment. The CMRS reliably predicts short-term retention in TC

treatment (De Leon and Jainchill 1986; De Leon et al. 1993, 1994;

Schoket 1992), and it holds promise for differentiating subgroups of

substance abusers with respect to their motivation and readiness for drug

treatment in general.

Treatment Stages and Planned Duration of Treatment. The process

stage formulation underscores the relationship between time in treatment

and treatment process. Retention is the most stable predictor of positive

treatment outcomes in TCs (Anglin and Hser 1991; De Leon 1985;

Hubbard et al. 1989; Institute of Medicine 1990; Tims and Ludford 1984;

Simpson and Sells 1982). Clinicians always have known that the

treatment effects in the TC were time correlated events. In the present

theoretical framework, these events reflect the stages of internalization. If

a significant degree of internalization of the TC teachings is not attained,

recovery is incomplete and the potential is greater for premature dropout,

relapse, or recidivism after leaving treatment.

47
These treatment process considerations bear upon several intersecting

issues—the differences among subgroups of substance abusers, the

treatment setting (residential/nonresidential), and the planned duration of

treatment (short, medium, or long). Research on these issues will have

important implications for policy and treatment planning as well as

science.

For example, clinical and research evidence has shown that the 18- to

24-month duration of treatment in long-term residential TCs has been the

optimal time period to achieve some level of internalized change.

However, increasing numbers of substance abusers who are homeless,

violent, psychologically disturbed, and unhabilitated underscore the

requirement for even longer periods of immersion in the TC recovery

process, given the extensive habilitative and rehabilitative needs of these

groups.

Even among the more socialized substance abuser, there is a need for a

sufficient period of treatment involvement to ensure some degree of

internalized change, regardless of treatment setting. Thus, the

effectiveness of shorter term TC-oriented residential, day treatment, and

outpatient programs will depend on appropriate matching of clients to

these different settings from a treatment and recovery stage perspective.

Research is needed to develop and evaluate the efficacy of assessment

protocols that guide such matching strategies.

Process and Design. In the TC, the change process unfolds as a

dynamic interaction between the community and the individual. In this

process, a self-selection activity is ongoing as individuals continually

make decisions about remaining in treatment based on their behavioral

and subjective changes. Thus, from a self-help recovery perspective, selfselection is not a problem, but a prerequisite for the effectiveness of

treatment. Treatment works because of client factors such as motivation,

readiness, and perceived suitability of the treatment.

This view of client self-selection contains important implications for

research designs in TCs, some of which have been discussed in other

writings (De Leon 1993). New design paradigms are needed that accept a

functional view of self-selection; namely, that treatment effectiveness

depends upon the client’s contribution to the process and outcomes.

Controlling for self-selection and isolating the specific effects of

treatment are less relevant than identifying the relative contribution of

these factors to the change process.

48
Treatment Process and Recovery. The present formulation stressed

the distinction between the process of treatment in the TC and the more

general process of recovery. The former refers to client change in

relation to the interventions, services, and activities of the TC. Recovery

is a broader term, referring to a continuing process of individual change

from active use or addiction to maintained sobriety. Many factors

contribute to the recovery process in addition to treatment. These relate

to the client (e.g., social and psychological resources); life circumstances

(e.g., social-economic potency, personal relationships, friendships, and

family); and specific events (e.g., health, personal, and material losses or

gains).

Treatment in the TC can be viewed as one significant facilitator of the

recovery process. Clients who achieve the social and psychological goals

of the TC are viewed as better prepared to positively engage life and to

continue in their recovery. In this sense, completion or graduation from

the TC represents the end of treatment, but it is also a stage in the

recovery process.

This distinction between treatment and recovery has important

implications for research, particularly with respect to evaluation of the

effectiveness of the TC. For example, shorter term success rates in the

period proximal to separation from treatment are more directly correlated

with the specific impact of the TC program. Longer term success rates,

however, are subject to a variety of influences that may obscure the

specific contribution of TC treatment. Of special relevance to these longterm outcomes, however, is the client’s recovery stage, particularly the

posttreatment integration stage described earlier. As noted in this stage,

the individual incorporates their treatment-based learning into their

general life experiences. From this stage perspective, fair and appropriate

evaluation of the effectiveness of TC treatment must assess both its

indirect and direct contributions to sustaining the individual’s long-term

recovery status.

CONCLUSION

Several caveats must be emphasized with respect to the present

theoretical formulation of the TC. First, it reflects the perspective of the

author and does not necessarily represent a position of consensus among

workers in TCs. Second, as noted, the essential elements are most

characteristic of the traditional long-term residential TCs; their relevance

49
for other TC-oriented programs (short-term residential and

nonresidential) remains to be empirically clarified. Third, a theoretical

formulation of the TC has obvious implications for training, clinical

practice, quality control, and funding. However, consistent with the

theme of the present monograph, this discussion has highlighted the

research considerations.

NOTES

1. The terms “components” and “elements” are used differently; the

former refers to the program model, while the latter refers to the

significant features of the general theoretical framework.

2. As discussed elsewhere, the TC community has features that are

common to other communities, such as schools, the prison, the

military, and even some corporations. Although closer in form to

extended families, villages, and some utopian communities, the TC

remains unique in how it uses the community as a method to change,

treat, or assist the individual (De Leon, in press).

3. A useful formulation of TC activities in terms of structure and

setting is provided by Frankel (1989).

4. Although perceptions and experiences remain to be operationally

defined, they are characterized elsewhere (De Leon, in press). In the

present framework, perception refers to how residents understand or

give meaning to what they see or hear. Experience refers to more

complex subjective events that include feelings and perceptions as

well as behavioral change. In the last analysis, however, subjective

events such as perceptions and experiences are indicated behaviorally

with certain words, deeds, and gestures.

5. Detailed descriptions of the program and process stages in the TC are

contained elsewhere (De Leon, in press). A more fully elaborated

recovery stage perspective drawn from the clinical and research

experience with TC residents is described in De Leon (1994b ).

6. The late reentry phase has been viewed by TCs as an aftercare stage,

although these agencies have been under funded for providing the

aftercare services of a fully developed continuance program.

50
REFERENCES

Anglin, D.M., and Hser, Y.-I. Treatment of drug abuse. In: Tonry, M.,

and Morris, N., eds. Drugs and Crime: Crime and Justice: A Review

of Research. Chicago: The University of Chicago Press, 1991.

Carroll, J.F.X., and Sobel, B.S. Integrating mental health personnel and

practices into a therapeutic community. In: De Leon, G., and

Ziegenfuss, J.T., eds. Therapeutic Communities for Addictions:

Readings in Theory, Research and Practice. Springfield, IL: Charles

C. Thomas, 1986.

De Leon, G. The therapeutic community: Status and evolution. Int J

Addict 20:823-844, 1985.

De Leon, G. The therapeutic community and behavioral science. Int J

Addict, 25th Anniversary Issue 25: 1537-1557, 1991a.

De Leon, G. Aftercare in therapeutic communities. Int J Addict 25: 1229-

1241, 1991b.

De Leon, G. What psychologists can learn from addiction treatment

research. J Addict Behaviors 7:103-109, 1993.

De Leon, G. Therapeutic communities. In: Galanter, M., and Kleber,

H.D., eds. Treatments of Substance Abuse. Chicago: American

Psychiatric Press, 1994a.

De Leon, G. A recovery stage paradigm and therapeutic communities. In:

Proceedings of the Second Therapeutic Communities Planning

Conference. Providence, RI: Manisses Communications Group,

1994b.

De Leon, G. The Therapeutic Community: Guide to Theory and Method.

New York: John Wiley and Sons, in press.

De Leon, G., and Jainchill, N. Circumstances, motivation, readiness and

suitability (CMRS) as correlates of treatment tenure. J Psychoactive

Drugs 8:203-208, 1986.

De Leon, G.; Melnick, G.; Kressel, D.; and Jainchill, N. Circumstances,

motivation, readiness, and suitability (The CMRS Scales): Predicting

retention in therapeutic community treatment. Am J Alcohol Drug

Abuse 20(4):495-515, 1994.

De Leon, G.; Melnick, G.; Schoket, D.; and Jainchill, N. Are therapeutic

communities culturally relevant? Some findings on race/ethnic

differences in retention in treatment. J Psychoactive Drugs 25:77-86,

1993.

De Leon, G., and Rosenthal, M.S. Treatment in residential therapeutic

communities. In: Karasu, T.B., ed. Treatments of Psychiatric

Disorders. Vol. II. Washington, DC: American Psychiatric Press,

1989.

51
De Leon, G., and Ziegenfuss, J., eds. Therapeutic Communities for

Addictions: Readings in Theory, Research and Practice. Springfield,

IL: Charles C. Thomas, 1986.

Frankel, B. Transforming Identities, Context, Power and Ideology in a

Therapeutic Community. New York: Peter Lang, 1989.

Galanter, M.; Egelko, S.; De Leon, G.; and Rohrs, C. A general hospital

day program combining peer-led and professional treatment of cocaine

abusers. Hosp Community Psychiatry 44:644-649, 1993.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh,

E.R.; and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press,

1989.

Institute of Medicine. Treating Drug Problems: A Study of the Evolution,

Effectiveness, and Financing of Public and Private Drug Treatment

Systems. Report by the Committee for the Substance Abuse Coverage

Study, Division of Health Care Services, Institute of Medicine.

Washington, DC: National Academy Press, 1990.

Melnick, G., and De Leon, G. “Essential Elements of Therapeutic

Treatment for Drug Abuse.” Paper presented at the 101st annual

convention of the American Psychologists Association, Toronto,

Canada, August 20-24, 1993.

Schoket, D. “Circumstances, Motivation, Readiness and Suitability for

Treatment in Relation to Retention in a Residential Therapeutic

Community: Secondary Analysis.” Ph.D. diss., City University of

New York, 1992.

Simpson, D.D., and Sells, S.B. Effectiveness of treatment for drug abuse:

An overview of the DARP research program. Adv Alcohol Subst

Abuse 2:7-29, 1982.

Tims, F.M. and Ludford, J.P., eds. Drug Abuse Treatment Evaluation:

Strategies, Progress and Prospects. National Institute on Drug Abuse

Research Monograph 51. DHHS Pub. No. (ADM)84-1329.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984.

Wexler, H.K., and Williams, R. The Stay’n Out therapeutic community:

Prison treatment for substance abusers. J Psychoactive Drugs 18:221-

230, 1986.

Winick, C. The counselor in drug abuse treatment. Int J Addict 25:1479-

1502, 1991.

52
AUTHOR

George De Leon, Ph.D.

Director

Center for Therapeutic Community Research

National Development and Research Institutes

11 Beach Street

New York, NY 10013-2114

53
Socialization Into the Therapeutic

Community Culture

Lorand Szalay

INTRODUCTION

This chapter describes a new analytic approach to process evaluation in

the treatment of drug addiction. This approach focuses on the assessment

of changes in the client’s self-image, relationship to the social

environment, perceptions of harmful substances, and on other variables

found to be significantly related to habitual drug use. The following

topics are covered: (1) a description of the Associative Group Analysis

(AGA) method; (2) findings obtained in a cross-sectional comparison of

200 pretreatment and 200 posttreatment clients at an urban therapeutic

community (TC) showing changes in dominant trends of perceptions,

attitudes, and cognitive organization; (3) differences in the perceptions

and evaluations of harmful substances by other groups of users and

nonusers; and (4) a discussion of a multidimensional strategy of process

evaluation in TC settings as a means of obtaining useful feedback on the

psychological effects of programs aimed at resocialization.

Approach

The investigations of pretreatment and posttreatment clients in a TC

setting focus on changes in psychological variables related to program

success. Analogous efforts to assess program effects have capitalized on

such personality traits as locus of control or alienation. Since the classic

efforts have remained surprisingly ineffective, the present approach goes

in distinctly different directions. It centers on perceptual and attitudinal

dispositions and on changes in cognitive organization in systems of

mental representation.

Students of human behavior working on theories of cognitive

representation assume that much of goal-oriented human behavior is

guided by cognitive maps or “systems of mental representation.”

Triandis (1972) wrote of a system of cognitions that constitutes a map of

the ways people conceive their environment. Tolman (1948) described

the maps as guidance or control systems that exert continuous influences

on choices and behavior. Mental representations include such diverse

54
notions as cognitive map (Tolman 1948), cognitive representation

(Downs and Stea 1973), internal representation (Posner and Keele 1968;

Shepard and Chipman 1970), subjective lexicon (Miller 1967), meaning

system (Osgood et al. 1957), and thought world (Whorf 1957). These

notions converge in the fundamental assumption that people’s behavior is

organized and guided by their subjective meanings and by the system of

subjective views they develop in the representation of their subjective

world.

Following psychological tradition, the main thrust of empirical research

that is designed to reconstruct systems of subjective representations is

centered on the assessment of subjective images and meanings.

Compared to lexical meanings based on linguistic use or convention,

psychological meanings are subjective reactions (Osgood et al. 1957) that

frequently encompass affects, personal experiences, and perspectives.

These constitute elementary units or mosaic pieces of the global system

of mental representation or world view. The system of subjective

representation is not merely an aggregate of subjective images and

meanings but a highly organized, coherent system. These

representational units are highly interdependent; each unit has to fit and

be adapted by the system. The AGA was used to assess subjective

images and meanings as representational units and to reconstruct the main

parameters of systems of mental representation.

The research was organized to test three main assumptions based on a

representational model of behavioral organization as follows.

1. By assessing subjective images and meanings, it is possible to

reconstruct perceptual and attitudinal dispositions differentiating

pretreatment drug addicts and rehabilitated clients.

2. The differences between active addicts and rehabilitated addicts are

not limited to single isolated images or meanings but reflect trends

across several themes (e.g., me, I am, friends) used in the

representation of broader domains (e.g., self/friends).

3. The systems of subjective representation can be charted in three

dimensions: perceptions, dominant priorities, and attitudes or

evaluations. The systems of addicts and rehabilitated clients can

serve as reference groups for determining the status of individual

clients and how much they have progressed in thinking like

successfully rehabilitated addicts.

55
METHOD

Subjects

The research was organized to test the potential of AGA to map the

systems of mental representation of pretreatment and posttreatment

samples and to measure changes in clients’ perceptions and attitudes

related to drug use. The research relied on a cross-sectional comparison

of pretreatment and posttreatment clients at an urban-based TC. The

TC is a long-term, residential treatment facility that emphasizes

resocialization and promotes behavioral changes that will reintegrate

the individual into society.

The pretreatment group consisted of 200 habitual drug users who were at

the beginning of their treatment at the TC. All members of this group

were hardcore users, predominantly of cocaine and crack. All suffered

from serious behavioral difficulties such as the inability to hold jobs or

earn a living, to function in normal family roles, or to meet personal

obligations. Most of the addicts entered treatment after reaching a level

of dependency that forced them to seek treatment. This group was

77 percent male and 23 percent female; the ethnic makeup of the sample

was 53 percent white, 36 percent black, and 10 percent Hispanic. Fiftyfour percent of the clients had been in drug treatment before.

The posttreatment group included 200 residents at the same TC who had

successfully reached a drug-free status and were in the final stages of

their rehabilitation program. These clients had spent an average of 1 year

and 8 months under strict regulation and control at this TC. They were

judged to be successful in their treatment by the following criteria:

maintaining a drug-free status over many months; assuming increasingly

demanding jobs and responsibilities within the TC and later in normal job

settings; and developing plans, holding to schedules, and developing

personal ties. This group was 74 percent male and 26 percent female; the

ethnic makeup of the sample was 48 percent white, 42 percent black,

9 percent Hispanic, and 1 percent Native American. In the posttreatment

group, 47 percent of the clients had previously been in drug treatment.

Drug users and nonusers in groups of similar size (n = 200) outside

treatment organizations also were included in some of the following

comparisons. These groups came from college populations tested across

the United States in the context of Department of Education interest in the

evaluation of prevention programs. Since these groups differed from the

56
client populations in average age and education, they were not used to

reach generalizations on treatment versus nontreatment. They served

mainly to illustrate differences in the psychological dispositions

associated with drug use and to test the effects of drug treatment on the

relationship of these groups.

The AGA method was administered to the above samples by using

stimulus themes covering several domains of life such as self-concept,

drug abuse, interpersonal and social relations, work, and future. The

standard AGA data collection procedures were used to elicit multiple

response, free associations to the selected themes.

The AGA

The use of word associations in the empirical study of word meanings has

its roots in the work of Noble (1952) and Deese (1965). As described in

Subjective Meaning and Culture (Szalay and Deese 1978), the AGA

method uses continued free association tasks to reconstruct the subjective

images and meanings of selected samples of respondents. The AGA is a

highly unstructured and open-ended analytical method which offers

access to behavioral dispositions beyond the reach of more direct and

more structured methods of assessment. It does not call for an overt

expression of personal position or opinions as no specific questions are

asked. The respondents perceive word associations as a language task

rather than an attempt to probe their personal beliefs or attitudes.

Data Collection, Test Administration. In its most common form, the

AGA uses association tasks administered in written form to selected

samples in group sessions. They receive the word themes (e.g., ME)

printed several times on slips of paper and are asked to write as many

ideas as possible related to each theme presented in 1 minute. On the

average, participants give six to eight different associations to each of the

words presented on each slip. As experiments have shown, the first

response to each theme is slightly more informative on the subjective

meaning than the next. These differences have been measured

experimentally by retesting the stability of responses at various rank

places and used to assign weight to the responses. The weights obtained

are as follows: 6, 5, 4, 3, 3, 3, 3, 2, 2, 1, 1, 1. The weighted responses of

the members of a particular sample group (e.g., pretreatment addicts)

were tallied into response distributions as shown in table 1.

57
TABLE 1. Highest scoring associations to ME

Pretreatment Posttreatment

Response Score Response Score

Love

Lonely,ness

Goodness

Bad

Confuse,d,ing,ion

Hat,red

Myself

Drug,s

Care, ing, for

Addict,s

Help,ing,ed

Hurt,ing

Therapeutic comm.

Alone

Selfishness

Understand,ing,able

Nice

Junkie

You

Future,istic

93 Love 69

55 Care,ing, for 66

46 Happy,ness 62

43 Good,ness 49

43 Myself 46

41 I 44

37 Kind,ness 36

35 You 31

31 Friend,s 29

28 Loving 23

25 Like 21

25 Afraid 20

22 Lonely,ness 18

21 Person 18

21 Scare,d,y 18

19 Self 16

19 Father,hood,ly 16

16 Responsible,ty 15

16 Alone 14

16 Straight 14

Mosaic Pieces of Perceptions and Evaluations. Table 1 presents

some of the most frequent responses elicited by the stimulus word ME

from two samples. Based on the distribution of hundreds of spontaneous

responses, such response lists offer many mosaic pieces of the

respondents’ subjective perceptions and evaluations. Each response has a

score value. These values reveal how salient a particular idea or attribute

is (loneliness, happiness) as a mosaic of the group’s self-image. A

perfunctory comparison of the responses suggests some characteristic

differences in the way pretreatment and posttreatment clients and

nonusers view themselves. For instance, the pretreatment clients show a

stronger sense of loneliness, and the posttreatment clients convey a

relatively happier view of the self.

Related responses form natural clusters and reveal mosaic pieces of the

group’s subjective meaning. Since the response distributions are

extensive, several analytic procedures have been developed to arrive at

more global and systematic conclusions. A simple method involves

content analysis; analysts trained in this process group the responses into

58
relevant main clusters or categories. For instance, responses conveying

insecurity and negative affects are placed in one cluster and labeled by

the most salient reactions: lonely, confused. All the references to

positive affects are placed in another cluster, and labeled again by the

highest scoring reactions: love, friendship.

As past studies (Szalay and Deese 1978) have shown, such

categorizations of content analysis can be performed with a reasonable

degree of reliability. The mean correlation between analysts working

independently was 0.7. An application of this procedure to the two

samples’ responses to ME resulted in the main response clusters shown in

table 2. The pretreatment group shows generally low self-esteem and

strong negative self-evaluations: loneliness, confused, hatred, and

hurting. As the references to drugs show, drug use is part of this group’s

self-image; they also identify themselves spontaneously as addicts and

junkies. Both treatment groups show a strong preoccupation with love

and caring, which corresponds to their affect-laden focus in other

domains such as family. Expressions of positive moods or evaluations

from the pretreatment group are few; the posttreatment clients are

considerably more positive with reactions such as happiness, friends,

loving, and responsible. Both the treatment samples, however, show

strong signs of internal anxieties and distress such as hurt, afraid, scared,

and lonely. These results offer many insights that are inaccessible

through direct questions, such as the intensity of ambivalent feelings and

the internal identification with a problem (e.g., drug use).

To convey the results of this analysis in a simple visual form,

“semantographs” are used (see figure 1). The semantograph is a graphic

presentation showing the differential salience of the main perceptual and

evaluative components of the groups’ subjective image. The bars of the

graph represent the main components of the groups’ self-image. On this

graph, the outlined bars show the relative salience of the perceptions and

attitudes of the pretreatment drug abuser group; the shaded bars show the

salience of these same perceptual and attitudinal components for the

posttreatment drug-free group. This technique of visual presentation is

used as a quick comparison of the identification of main similarities and

differences. On select clusters where the differences appear sizable, the

actual reactions of the groups are listed in detail. Several analytic

measures have been applied to gauge cognitive organization along such

main dimensions as perceptions, priorities, and evaluations.

Subjective Perceptions, Representations. The similarity of

subjective views and perceptions of a particular theme for different

groups is measured by comparing the distributions of their free

associations using Pearson’s measure of product-moment correlation.

For groups, the reliability of this measure based on split-half comparison

over 40 themes was 0.82 (Szalay and Bryson 1973). Perceptual

59
TABLE 2. Main components of perception and evaluation of ME by

pretreatment and posttreatment samples

Percentage of

Total Score

Main Components PRE POST

Lonely, confused, hate 35 12

Love, friendship 16 20

Good, kind, loving 14 14

Drugs 10 3

Happy, healthy, strong 2 15

I, myself 5 13

Family, others 4 9

Studious, intelligent 4 3

Appearance, sex 3 1

Individual, person 2 3

Future, working 3 5

Miscellaneous 2 3

Total Scores 969 970

similarity scores also can be computed for each individual with reference

to the distributions of free associations characteristic of the groups being

compared. For each stimulus word, responses that differentiated the

groups (e.g., drug users and nonusers) are identified. Each such response

is scored +1 if it is more characteristic of one group (e.g., nonusers) or -1

if it is more characteristic of the other group (e.g., drug users). In this

manner, individual perceptual similarity scores are calculated for all

respondents. Discriminant function analysis of this variable correctly

identified 88 percent of the respondents (n = 400) in one study as

frequent drug users or nonusers (canonical correlation (can. corr.) =.78,

chi-square = 376.7, p < .000).

Subjective Priorities, Importance. In a person’s subjective

representation of the world, some subjects, issues, and ideas play more

important roles than others. Drugs may be dominant in the lives of drug

users but not of nonusers. The importance or dominance of a particular

stimulus theme to a particular person or group is inferred from the

number of responses offered in the association task. The dominance

scores calculated both on an individual and group basis are analogous to

Noble’s (1952) widely tested measure of “meaningfulness.” These scores

have been used to measure differences between groups in their subjective

priorities, as well as to trace changes in priorities over time. The

reliability of the group dominance score (r = 0.93) was measured by test60
FIGURE 1. Perceptions and evaluations of ME
retest comparison (Szalay and Bryson 1973). Individual dominance

scores are computed as the number of responses given to each stimulus

theme. Discriminant function analysis of this measure correctly

identified 64 percent of the respondents in one study as frequent users or

nonusers (can. corr. = .33, chi-square = 45.7, p < .005). A dominance

similarity score, calculated on the basis of discriminant function

coefficients for the individual dominance scores, shows whether a person

belongs more to one group or another (e.g., a user or nonuser group or a

pretreatment or posttreatment group).

Subjective Affects, Evaluations. Perception of the environment is

loaded with positive and negative evaluations and affects. Certain

elements are seen as desirable and attractive and others as aversive and

harmful. Evaluations and affect-loading are terms that are closely

synonymous with attitudes, the most widely researched subject area of

psychology. As extensive research has demonstrated, affects—positive

versus negative evaluations—are important psychological variables. One

of the ways to reconstruct how a person or group evaluates a particular

stimulus theme is to calculate the predominance of positive versus

negative responses to it. The Evaluative Dominance Indices, calculated

on the basis of positive versus negative reactions, produce very high

positive correlations of 0.88 to 0.91 with independent attitude measures

(e.g., semantic differential) (Szalay et al. 1970).

Evaluative scores also can be calculated on an individual basis. The list

of responses to all the stimulus words are reviewed by two judges. The

two judges rate each response word in terms of its positive or negative

affect (interjudge correlation coefficient = 0.95, p < .001). The ratings of

the two judges are averaged and subsequently used to infer the evaluation

of each stimulus theme by each subject. For each subject, the evaluation

of each stimulus theme is computed by averaging the judges’ evaluation

of the response words. Discriminant function analysis of this measure

has correctly identified 69 percent of the respondents in one study as

frequent drug users or nonusers (can. corr. = .46, chi-square = 90.9,

p < .000). An evaluative similarity score, calculated on the basis of

discriminant function coefficients for the individual evaluative scores,

shows whether a person belongs more to one group or another (e.g., to a

user or nonuser group or to a pretreatment or posttreatment group).

RESULTS: PROGRAM EFFECTS, IDENTlFlCATlON OF THE

REHABlLlTATED

The following results show differences/changes in perceptions or

subjective representations of pretreatment and posttreatment clients

measured in selected domains of life and in their overall systems of

representation.

62
Program Effects Measured in Selected Domains of Life

Results are presented on perceptions and attitudes in the domains of

SELF/FRIENDS and PROBLEMS.

Self/Friends. The following general observations are based on the

analysis of the themes I AM and FRIENDS shown in figures 2 and 3.

Perceptions in this domain provide a measure of the self-esteem and

confidence of the treatment groups. The pretreatment group reveals a

very low level of satisfaction with themselves, while the posttreatment

group expresses much more confidence and self-worth. These selfperceptions are reflected in their opinion of friends and friendship. The

pretreatment clients have a deeper sense of loneliness than the

posttreatment clients. They mention the absence of friends in their lives.

They are preoccupied with negative aspects of both themselves and their

friends, such as hurting, hate, and badness. They also link themselves

and their friends more to drugs and addiction. They have low selfesteem, and they have very mixed feelings about friends.

The posttreatment clients have more faith and confidence in themselves

and in friends. They are happier with themselves and with their friends.

They see themselves and their friends as more caring and loving, honest,

and trustworthy. They have been helped by their friends and see them as

supportive. The friendships experienced in the TC seem to have had a

very positive effect on the clients’ self-esteem and on their ability to trust

and rely on others.

Problems. Similarly consistent trends emerged across themes used in

the representation of this domain. Two are presented here: PROBLEMS

(figure 4) and WORRIES (figure 5). The two groups again show

differences in self-esteem. The pretreatment group has much lower selfimage and is focused on internal personal problems; the posttreatment

group has more self-confidence and is more externally oriented.

In the context of PROBLEMS, WORRIES, and LONELINESS, the

pretreatment clients refer to themselves more frequently than the

posttreatment clients, revealing that they have a more negative self-image

and are more conscious of having emotional problems. They also tend to

view personal and familial relationships as a predominant problem.

The posttreatment clients are more outwardly oriented. They show more

apprehension about money and success. Anticipating their departure

from the TC, they are concerned with work, jobs, and school. It seems

that these clients have come to better terms with themselves and have

greater confidence in their ability to find solutions to problems as they

move back into the world. After treatment they also show more

63
FIGURE 2. Perceptions and evaluations of I AM
FIGURE 3. Perceptions and evaluations of FRIENDS
FIGURE 4. Perceptions and evaluations of PROBLEMS
FIGURE 5. Perceptions and evaluations of WORRIES
FIGURE 6. Dominant trends of perceptions and evaluations

differentiating pretreatment and posttreatment clients

Pretreatment

Trends

Scared, lonely

Angry, bad

Hurt, confused

Addict, drugs

Lonely, confused, hurt

Hate, anger

I, myself

Drugs

None, don't have

Family

Bad, hate

Fighting, trouble, stealing

Pretreatment

Hate, anger, bad

Hurt, confused, scared

Lonely, lack of friends

Addict, drugs

Drugs

Many, always, life

Self, me

Family, mother, children

THEMES

I am

Me

Friends

DOMAINS

Self/Friends

Domain

Problems

Domain

Posttreatment

Trends

Happy, fun

Good, caring

Honest, loyal, trustworthy

Responsible, respected, proud

Happy, fun

Good, caring

Appearance

Honest, loyal reliable

Love, caring

Trusting, honest

Need, good, specific names

Fun, happy

Posttreatment

Good, love, caring

Happy, fun

Honest, trustworthy,

loyal

Appearance

Work, job, school

Solve, overcome

Love, trust

Death, health

68
sensitivity to pain and hurt, health, and illness, particularly the idea of

death.

The results obtained in these domains have shown several characteristic

differences between pretreatment addicts and rehabilitated clients who

have reached a stable drug-free status. Figure 6 illustrates trends or

perceptions and evaluations that set the rehabilitated posttreatment group

apart from the pretreatment addicts.

In general, the results show changes in clients’ subjective views and in

their systems of mental representation in important domains related to

drug abuse. At the same time, the findings offer a host of partially

contrasting perceptual and evaluative dimensions to trace client progress

in domains related to drug use and program success.

Perceptual and Attitudinal Trends Differentiating Drug Users

and Nonusers

The comparison of pretreatment and posttreatment client samples

revealed marked differences in their views and attitudes, which are

explicable largely by the effects of the treatment process and by the

influences of the treatment environment. The nature and consistency of

these differences lead to the question: Can such differences be identified

between drug users and nonusers as well?

Extensive comparative studies conducted with elementary to college-level

students across the country allow the author to answer this question

conclusively and affirmatively. To illustrate such differences, the next

section compares user and nonuser college students on their image of

MARIJUANA (figure 7) and on their image of DRUGS (figure 8).

Again, studies found highly consistent trends across several themes

(MARIJUANA, DRUGS, GETTING HIGH, and ALCOHOL), showing

that the users consistently pay more attention to the fun and entertainment

value and the high and euphoric effects of these substances. They show

more awareness of altered states of mind. The users are more familiar

with types and brands of drugs and alcohol, and they tend to make more

references to hard drugs and hard liquors. They do not pay such close

attention to the harm or health hazards of addiction; in general, they have

much more positive attitudes toward drugs, alcohol, and addiction. In

addition, there is a stronger association between the use of harmful

substances and sex. The nonusers, on the other hand, show more

awareness about and concern with the lawfulness and addictive nature of

drugs. They emphasize danger, death, and killing, and they show more

negative attitudes and categorical rejection. The nonusers focus on drugs

and alcohol in general terms rather than on specific types or varieties;

they are less familiar with slang terms. They also have a stronger

69
FIGURE 7. Perceptions and evaluations of MARIJUANA
FIGURE 8. Perceptions and evaluations of DRUGS
identification with marijuana as a drug. These differences between drug

users and nonusers are not limited to the perception of drugs; they

involve several other domains, ranging from self-image to the view of the

social environment.

Testing the Use of Perceptual/Representational

Data to Identify Changes in Behavior

Finally, it is of interest to examine how useful the perceptual/evaluative

information obtained through the AGA is in differentiating people with

different behavior. How successfully can it differentiate those who have

completed the treatment program and have maintained a drug-free status

for several months from the addicts who have just started treatment? To

answer this question, one may rely on the three AGA measures to assess

the system of cognitive behavioral organization along three of its main

dimensions.

1.

2.

3.

To chart changes in priorities reflected by differences in the

subjective importance or meaningfulness of the themes examined,

dominance scores were calculated based on the number of responses

to each theme produced by each respondent in both the pretreatment

and posttreatment groups.

To assess changes in the perceptual dimension of subjective

meanings, individual perceptual similarity scores were calculated.

These scores show the correspondence between the client’s responses

to each theme and the response distributions of pretreatment and

posttreatment groups across all 40 themes.

To measure changes in the dimension of attitudes or evaluations, the

differences between pretreatment and posttreatment individual

evaluative scores were calculated based on the evaluation scores

obtained for each of the 40 themes.

The individual scores were analyzed for their potential to accurately

identify whether respondents belonged to the pretreatment or the

posttreatment group. Discriminant function analyses of the three types of

scores based on 40 themes were used to show the percentage of cases

correctly classified: 87 percent based on the perceptual measure (can.

corr. = 0.75, chi-square = 327.3, degrees of freedom (DF) = 1, p < .000);

75 percent based on the dominance measure (can. corr. = .56, chi-square

= 140.4, DF = 40, p < .000); and 77 percent based on the evaluative

measure (can. corr. = 0.62, chi-square = 187.6, DF = 40, p < .000). The

accuracy of identification shows a high correspondence between

AGA-based perceptual/attitudinal information and behavior:

pretreatment drug dependence versus posttreatment drug-free status.

72
Results based on the individual perceptual similarity measure are

presented in figure 9. Discriminant analysis was used on this one

variable (based on responses to 40 themes) for convenience in showing

the percentage correctly classified, and a histogram was created in a

format comparable to the results presented in figure 10. So far, this

variable has shown the strongest relationship to behavior. Since the

results in figure 9 are based on within-group comparisons for which the

individual subjects may have contributed to the norms used in the

evaluation, a second test split the pretreatment and posttreatment samples

and measured perceptual similarity across independent samples. Under

these conditions, the correlations between perceptual similarity and

pre/post status dropped from 0.85 to 0.66, still a very strong relationship.

Correct classification dropped from 94 percent to 80 percent, again still

high. Since these figures are based on 200 subjects, it is difficult to

compare them directly with the correlation of 0.75 and 87-percent correct

classification obtained for the sample of 400. However, these figures are

higher than the cross-group results based on 100 respondents and lower

than the within-group results based on 100 respondents.

Discriminant function analysis also was used to assess the accuracy of the

identification of drug users versus nonusers based on dominance,

perceptual similarity (cross-group), and evaluative scores generated from

the responses of 400 college students in the context of 24 themes.

Results based on all three measures combined are presented in figure 10.

The percentage of cases correctly identified by discriminant function

analysis was 77 percent based on the criterion of self-report.

Essential Characteristics of the Method and Their Relevance

to TCs

TCs represent a treatment modality that places a strong emphasis on the

resocialization of clients. TCs use the power of social influences—the

internal dynamics of close community settings where the clients live

together and share their problems over many months and even years.

These social forces and dynamics are directed by the treatment process

toward helping clients overcome the debilitating effects of their chemical

dependencies. TCs help to develop a new outlook on life that is

conducive to coping with the problems of life and to developing a drugfree lifestyle.

The results of this investigation offer new empirical evidence on the

depth and nature of perceptual and attitudinal dispositions and changes in

dynamic client variables that make a critical difference in influencing the

outcome of the treatment process. The results show the effectiveness of

the AGA to assess client variables systematically along three major

dimensions of cognitive/behavioral organization: priorities, perceptions,

and attitudes that reflect the impact of treatment. The extent and nature

73
FIGURE 9. Identification of client status based on perceptual

similarity

74
FIGURE 10. Identification of drug users and nonusers based

on perceptions, evaluations, and dominance

75
of changes indicate the client’s progress from perceptions and attitudes

characteristic of drug addicts toward perceptions and attitudes

characteristic of those who have reached a drug-free status more or less

permanently. The results provide valuable insights into the

resocialization process through access to highly subjective perceptual and

motivational variables, where changes occur mostly below the level of

the client’s conscious awareness and are almost inaccessible through

direct techniques that use questions and scales.

The investigations offer new empirical evidence of a close relationship

between drug abuse and psychological makeup (i.e., the dominant

perceptions and attitudes of the drug abuser). They demonstrate the

importance of the socialization process as a natural means of achieving

the desired changes. The investigations show that changes in relevant

perceptions and attitudes correlate significantly with changes in drug

dependence. The demonstration of this relationship is of special

relevance to the TC model, which works toward such changes by using

resocialization as the main focus of the treatment process. By showing

the close relationship between psychological dispositions and drug

dependence, it becomes possible to test to what extent resocialization of

the addict is necessary for successful rehabilitation.

Three Major Fields of Practical Applications

Identification of Critical Treatment Variables. The author’s

investigations have identified five or six main dimensions, such as selfimage and relationship to others, that are significantly related to treatment

success. There are indications that this may be a somewhat incomplete

list, but it does provide a solid foundation for practical use. By testing

additional pretreatment addicts and clients who have successfully reached

drug-free status after completing a full treatment cycle, the AGA method

offers a promising analytic tool for obtaining group profiles on relevant

pretreatment and posttreatment populations. These population norms and

profiles provide opportunities to gain insights into the effects of various

treatment strategies, treatment modalities, environmental conditions,

gender, and ethnicity on the success of the treatment process. The

psychosocial parameters of the treatment process that have been

recognized as important are made more accessible through investigations

that rely on the AGA in tracing the relevant variables.

Monitoring Treatment Progress of Individual Clients. By

administering an instrument developed for this task to diagnose

individual clients, progress toward response norms developed from

successfully treated drug-free clients can be systematically assessed along

relevant dimensions such as self-image, relationship to family and

friends, and perception of harmful substances. The diagnostic profile that

emerges from such an assessment can be used to show a particular

76
client’s overall position in the process toward the final goal of stable

drug-free status. The diagnostic profile also offers information on

treatment progress achieved by the client along the main dimensions that

are critical to program success. Dynamic client variables, particularly

perceptions, have been identified by recent findings as most promising in

predicting retention and treatment success (Condelli and De Leon 1993;

De Leon 1991).

Therapy and Counseling of Clients. In addition to extending the field

of quantification to client variables that had been beyond the reach of

more structured instruments, the AGA method produces rich empirical

insights into perceptual and motivational dispositions that are valuable in

therapy and counseling. These insights show how individual clients or

their cohort perceive and evaluate problems and determine their

subjective construction of reality. Sterman (1991), for example, spoke of

the task involved in reducing the distance between the client’s private

meanings in his or her own representational system and the public

meanings in his or her external world. This type of information is

relevant to clinicians and counselors working along the models of

logotherapy (Frankl 1962), cognitive behavior therapy (Beck 1976),

rational-emotive therapy (Ellis 1962; Ellis and Murphy 1975), and

neurolinguistic programming (Bandler and Grinder 1982). The AGAbased information helps the counselor or therapist to approach the

subjective world of the client and reframe the client’s subjective world as

necessary to promote the desired behavioral change or outcome.

Much of the strength of the AGA method lies in its intrinsic

characteristics as a nondirective, inferential approach and nontransparent

strategy in assessing perceptions and motivations without asking direct

questions. The AGA’s potential to reveal dominant dispositions of which

the clients themselves are frequently unaware underscores its value in

application to process evaluation in TCs.

REFERENCES

Bandler, J., and Grinder, R. Re-framing: Neuro-Linguistic Programming

and the Transformation of Meaning. Mohab, UT: Real People Press,

1982.

Beck, A.T. Cognitive Therapy and the Emotional Disorders. New York:

New American Library, 1976.

Condelli, W.S., and De Leon, G. Fixed and dynamic predictors of client

retention in therapeutic communities. J Subst Abuse Treat 10:11-16,

1993.

Deese, J. The Structure of Associations in Language and Thought.

Baltimore: John Hopkins Press, 1965.

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De Leon, G. Retention in drug-free therapeutic communities. In: Pickens,

R.W.; Leukefeld, C.G.; and Schuster, C.R. eds. Improving Drug

Abuse Treatment. National Institute on Drug Abuse Research

Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC:

Supt. of Docs., U.S. Gov. Print. Off., 1991.

Downs, R.M., and Stea, D. Image and Environment: Cognitive Mapping

and Spacial Behavior. Chicago: Aldine, 1973.

Ellis, A. Reason and Emotion in Psychotherapy. New York: Lyle Stuart,

1962.

Ellis, A., and Murphy, R. A Bibliography of Articles and Books on

Rational-Emotive Therapy and Cognitive-Behavior Therapy. New

York: Institute of Rational Living, 1975.

Frankl, V.E. Man’s Search for Meaning: An Introduction to

Logotherapy. New York: Simon and Schuster, 1962.

Miller, G.A. Psycholinguistic approaches to the study of communication.

In: Arm, D., ed. Journeys in Science. Albuquerque: University of New

Mexico Press, 1967.

Noble, C. An analysis of meaning. Psychol Rev 54:421-440, 1952.

Osgood, C.E.; Suci, G.J.; and Tannenbaum, P.H. The Measurement of

Meaning. Urbana, IL: University of Illinois Press, 1957.

Posner, M.I., and Keele, S.W. On the genesis of abstract ideas. J Exp

Psychol 77:353-363, 1968.

Shepard, R.M., and Chipman, S. Second order isomorphism of internal

representations: Shapes of state. Cogn Psychol 1:1-7, 1970.

Sterman, C.M. Neuro-linguistic programming as psychotherapeutic

treatment in working with alcohol and other drug addicted families.

Chemical Dependency: Theoretical Approaches and Strategies. 1991.

pp. 73-75.

Szalay, L.B., and Bryson, J.A. Measurement of psychocultural distance:

A comparison of American blacks and whites. J Pers Soc Psychol

26:166-177, 1973.

Szalay, L.B., and Deese, J. Subjective Meaning and Culture: An

Assessment Through Word Associations. Hillsdale, NJ: Lawrence

Erlbaum/Wiley, 1978.

Szalay, L.B.; Windle, C.; and Lysne, D. Attitude measurement by free

verbal associations. J Soc Psychol 82:43-55, 1970.

Tolman, E.C. Cognitive maps in rats and men. Psychol Rev 55:189-208,

1948.

Triandis, H.C. The Analysis of Subjective Culture. New York: Wiley,

1972.

Whorf, B. Language, Thought and Reality. New York: Technological

Press/Wiley, 1957.

78
AUTHOR

Lorand Szalay, Ph.D.

Director

Institute for Comparative Studies

6935 Wisconsin Avenue, Suite 500

Chevy Chase, MD 20815

79
Client Outcomes From

Therapeutic Communities

Ward S. Condelli and Robert L. Hubbard

INTRODUCTION

This chapter discusses research on client outcomes from therapeutic

communities (TCs) and other types of residential treatment programs for

substance abusers. The first section compares findings from two large

studies of TCs: the Drug Abuse Reporting Program (DARP) in the early

1970s and the Treatment Outcome Prospective Study (TOPS) in the early

1980s. These studies were funded by the Federal Government to evaluate

the effectiveness of U.S. drug treatment programs. The second section

compares characteristics of clients from the TCs and other long-term

residential programs that participated in TOPS. The third section assesses

the effects of both types of programs on client outcomes when client

characteristics and drug treatment during the followup year are taken into

account. The chapter concludes with a discussion of research that is

needed to better understand and improve client outcomes from TCs.

Research on client outcomes from TCs generally has fallen into one of

three types of studies: (1) single TCs, (2) multiple TCs, or (3) multiple

long-term residential programs that included TCs. An example of the

first type of research is a study conducted by De Leon (1984) that focused

on 400 dropouts and 125 graduates from Phoenix House, a large

traditional TC located in New York City. Bale and associates (1980)

conducted a study that provides an example of the second type of

research. This study randomly assigned clients to drug treatment

programs in the San Francisco Bay area, then compared the outcomes of

361 clients from three TCs. Another example is a series of followup

studies conducted by Sells and Simpson (1976) and Simpson (1979,

1981) on admissions to more than two dozen DARP TCs in 1969-73.

Alternatively, Hubbard and colleagues (1989) assessed the outcomes of

731 clients in the 17 TCs and other types of residential programs that

participated in TOPS in 1979-81. Whether the research was done at

single or multiple TCs, or at multiple long-term residential programs that

included TCs, results generally have been the same: clients who stayed

in programs for long periods of time had lower rates of drug use and

criminal behavior, and higher rates of employment and school attendance,

80
than clients who stayed in programs for short periods of time (Bale et al.

1980; De Leon 1984; Hubbard et al. 1989; Simpson 1979).

Table 1 shows that the results of these studies varied, however, in terms

of the amount of time they found clients needed to stay in programs to

produce the desired outcomes and in particular outcomes they found

related to time spent in programs. For example, the study done by Bale

and associates (1980) found decreases in use of heroin and other types of

illegal drugs, arrests or convictions, and unemployment among clients

who stayed in programs for as little as 50 days. Simpson (1979) reported

that clients needed to spend at least 90 days in programs before they

began to show reductions in opioid (e.g., natural and synthetic opiates)

and nonopioid use, arrests, and unemployment. De Leon and colleagues

(1982) found that clients needed 4 to 6 months of treatment to produce a

decline in opiate use and criminal behavior and more than 9 months to

increase employment. Hubbard and associates (1988, 1989) reported that

clients needed 6 to 12 months of treatment to reduce predatory crimes

and a year or more of treatment to increase employment and to decrease

use of heroin, marijuana, and other drugs.

Differences in client populations, program characteristics, and outcome

measures could account for the variability in findings across these studies.

Bale and associates (1980) focused on veterans, who are likely to have

more social and economic skills and resources than other clients, and thus

may not have needed to spend as much time at programs before showing

favorable outcomes from them. Another important difference between

this study and the others was the timeframe used to assess drug use

outcomes: rather than assessing drug use during all 12 months of the

followup year, this study focused on drugs used only during the 12th

month. Such measures are likely to underestimate drug use during the

followup year (Anglin and Hser 1990). Because the research conducted

by Bale and associates (1980) and De Leon (1984) was based on either

single or small numbers of programs, it is not clear to what extent their

findings are representative of TCs in general. Due to variations within

types of programs, some programs may be more effective than others in

producing favorable client outcomes.

Although Simpson’s (1979) study was based on a large sample of TCs,

some programs that were suspected to be substandard were referred to

DARP in an effort to put them under surveillance (Ginzburg 1978).

Thus, this study may have underestimated the effects of shorter time

spent in treatment on client outcomes due to oversampling of ineffective

81
TABLE 1. Time needed to affect client outcomes from programs

Study

Bale et al. 1980

Simpson 1979

De Leon et al. 1982

Hubbard et al. 1989

Sample

3 TCs

n = 361

24 TCs

n = 735

1 TC

n=525

10 TCs,

7 other

residential

n = 731

Time

50+ days

90+ days

120- 180 days

270+ days

190-365 days

365+ days

Outcome

Heroin & other

drugs

Arrests

Employment

Opioids & other

drugs

Arrests

Employment

Heroin

Criminal behavior

Employment

Criminal behavior

Heroin & other

drugs

Employment

programs. While the research conducted by Hubbard and colleagues

(1988,1989) also was based on a large sample of programs, the longer

amount of time needed to affect client outcomes is at variance with that

reported by most other studies. Moreover, because TOPS was based on a

82
mixture of TCs and other types of residential programs, the aggregate

findings of this study may not be generalizable to TCs per se.

Long-term residential programs in the United States often trace their roots

back to TCs founded by Synanon, Daytop Village, and Phoenix House in

the late 1950s and 1960s (Biase 1985; Casriel 1963; De Leon 1974;

Volkman and Cressey 1966; Yablonsky 1965). Programs established all

over the country during the 1960s and 1970s, however, may not have

developed in the same manner as the original TCs. Only half of the

residential programs that participated in TOPS in 1979-81 were members

of Therapeutic Communities of America (TCA), which suggests that not

all of them subscribed to the same treatment philosophy. Indeed, by the

time TOPS was conducted, some long-term residential programs may

have evolved to the point where they had little in common with TCs

besides providing treatment in residential settings. The aim of this

chapter is to assess whether the TCs had different effects on client

outcomes than the other types of residential programs that participated in

TOPS.

METHODS

The data for analyzing client outcomes from residential programs came

from TOPS, which was conducted by Research Triangle Institute. This

study was sponsored by the National Institute on Drug Abuse (NIDA)

through a series of grants and contracts. Included in the study were

publicly funded outpatient methadone, long-term residential, and

outpatient drug-free programs.

A sample of 12,000 clients were interviewed at the time of admission to

41 publicly funded drug abuse treatment programs in 10 metropolitan

areas in the United States between 1979 and 1981. Approximately

24 percent (2,887) of the clients were admitted to the 17 long-term

residential programs. Of these, 62 percent (1,790) were admitted to the

10 TCs. Followup questionnaires were administered to probability

samples of clients stratified by year of admission, program, and time

spent in the program. TOPS followed up 731 of the 2,887 admissions

1 year after they left their programs. About 60 percent (436) of these

clients were from TCs located in Chicago, Miami, New Orleans, New

York, Philadelphia, Phoenix, and San Francisco. Data collection and

sampling procedures for TOPS have been described in detail elsewhere

(Hubbard et al. 1989).

83
Predictor Variables

A wide range of variables was used to predict client outcomes from

TOPS residential programs. Demographic variables included gender,

race/ethnicity, age, education, and marital status. Background variables

were based on behavior in the year before admission. These included

working full-time (35 or more hours per week) for at least 40 weeks and

committing predatory crimes such as assault, robbery, burglary, theft,

embezzlement, forgery, and selling or receiving stolen property. The

number of drug-related problems were recorded in the following areas:

medical or physical; mental health or emotional; family or friends; police

or legal; job, work, or school; and financial or money. Any history of

suicidal thoughts or attempts in that year was used as an indicator of

depression.

This study distinguished among seven patterns of drug use. These

patterns form a hierarchy that was derived from a cluster analysis of types

of drugs used by clients during the year before admission (Hubbard et al.

1986). Clients were assigned to the first two patterns in the hierarchy

according to whether they used heroin alone or with other narcotics on a

daily or weekly basis. Of the remaining clients, those who used other

narcotics on a daily or weekly basis were assigned to the third pattern in

the hierarchy, and the same procedure was used to assign clients to the

following patterns: multiple nonnarcotics, single nonnarcotics,

alcohol/marijuana, and minimal drug use. The first two patterns served

as the comparison group for the other patterns of drug use. A separate

variable was created to take into account heavy use of alcohol during the

year before admission to the program. This variable compared clients

who consumed five or more drinks in a single sitting per week with those

who used less alcohol. The variable was coded to be consistent with

standard definitions of heavy alcohol use (Clark and Midanik 1982).

Finally, the analysis took into account the number of prior admissions to

drug treatment programs and whether clients were referred to TOPS

programs from the legal system, by their families or friends, or by

themselves. The time in treatment variables included the number of

months spent in TOPS residential programs and variables representing

time spent in drug abuse treatment programs during the followup year.

84
Outcome Variables

Seven outcome variables were selected to assess the effectiveness of

treatment on the behavior of clients during the year after they left the

programs. Four of these were drug use variables: daily or weekly use of

heroin, cocaine, marijuana, and psychotherapeutic drugs; the last category

included tranquilizers, barbiturates, sedatives, hypnotics, and

amphetamines. To simplify matters, daily or weekly heroin use will be

referred to as heroin use, and the same operational definitions will apply

to other types of drug use. The other outcome variables were heavy

alcohol use, number of predatory crimes, and steady full-time

employment (i.e., working 35 or more hours per week for 40 or more

weeks).

Data Analysis

Logistic regression was used to assess the effects of time spent in

programs on the seven outcome variables. The analysis took into account

the following variables because they were likely to affect patterns of drug

and alcohol use, employment, and criminal behavior during the followup

year: client demographic and background variables and time spent in

drug abuse treatment programs during the year after clients left TOPS

programs.

Adjusted odds ratios were used to display results for predictors of the

respective outcomes shown in tables 6 and 7. With the exception of

number of months spent in TOPS residential programs, all variables were

categorical. Odds ratios for categorical variables represent the odds of the

respective outcome for clients who had the attribute indicated by the

variable, relative to the odds for clients in a selected reference category

(Hosmer and Lemeshow 1989). Odds ratios for number of months spent

in TOPS programs represent the odds of the respective outcome relative

to the odds for clients who had spent 1 month less in the program. Chisquare was used to test the significance of the odds ratios; asterisks on

tables 6 and 7 indicate the level of probability at which they were

significant.

RESULTS

The first step in the research was to compare demographic characteristics

of the 4,361 clients admitted to DARP programs with those of the 1,790

85
clients admitted to TOPS programs. Table 2 shows that there were slight

differences in the composition of males and females and minor

differences in the composition of racial and ethnic groups among clients

admitted to these programs. Clients who joined TOPS programs in

1979-81 were not markedly different from those who joined TCs that

participated in the 1979 TCA study (Condelli and De Leon 1993). The

most striking difference between clients in DARP and TOPS was the

percentage who were over 25 years of age. Almost half (47 percent) of

those in TOPS were over age 25, while the corresponding percentage for

those in DARP was 25 percent. Research indicates that age is an

important predictor of retention in TCs (Condelli 1986, 1989).

A comparison was done of behaviors of clients admitted to DARP and

TOPS TCs. The DARP data discussed below were compiled from a

1-year followup report on 966 black and white male clients from TCs

(Simpson and Sells 1982). Clients with these characteristics had been

selected for analysis due to their consistent representation across all

treatment groups. Information on the drug abuse treatment programs that

participated in DARP has been described in detail elsewhere (Sells and

Simpson 1976).

To compare findings across studies, all 405 black and white male TC

cases in TOPS data files who had been followed up were selected. Most

of the behavioral data collected by DARP and TOPS pertained to the year

before admission and the year after termination from programs. These

studies differed, however, in the baseline used to measure drug use:

DARP used the 2 months prior to admission, whereas TOPS used the 12

months prior to admission.

Drug Use

Table 3 presents findings from DARP and TOPS on the drug use

outcomes of clients from TCs. Twice as many daily opioid users joined

TCs in DARP than in TOPS. This threshold is important because experts

believe that physiological addiction is likely to occur when opioids are

used on a daily or more frequent basis for more than a short period of

time (Brecher 1972). The higher rates of opioid use found by DARP may

be partly due to this study using a shorter (i.e., 2 months versus 12

months) baseline period than TOPS (Anglin and Hser 1990).

Nevertheless, these studies suggest there was more multiple drug use

among clients in TOPS than in DARP.

86
TABLE 2. Characteristics of clients admitted to DARP and TOPS

therapeutic communities

Client Characteristics

Male 74 79

Female 26 21

Black 36 27

Hispanic 14 9

White (Non-Hispanic) 49 63

Other 1 1

Under 18 years 13 10

18-25 years 62 43

Over 25 years 25 47

DARPa TOPSb

1969-73 1979-81

% %

KEY: an = 4,361; bn = 1,790

Table 3 also shows clients’ patterns of drug use before they joined DARP

TCs and during the year after they left those programs. The number of

daily opioid users declined from 60 percent to 33 percent. Use of opioids

declined from 83 percent to 51 percent. The number of nonopioid users

fell from 61 percent to 43 percent. Even greater reductions in drug use

were found among clients who joined TOPS programs. The number of

daily opioid users declined from 39 percent to 9 percent. Use of opioids

fell from 68 percent to 38 percent, and use of nonopioids fell from 90

percent to 55 percent.

Criminal Behavior

Table 3 indicates that a larger percentage (92 percent versus 68 percent)

of clients in DARP than in TOPS were arrested during the year before

admission. This may be due to DARP having more daily opioid users.

87
TABLE 3. Changes in clients admitted to DARP and TOPS therapeutic

communities *

Client Characteristics DARPa

1969-73

Pre Post

% %

Opioids

Daily use

Any use

60 33

83 51

Nonopioids

Any use 61 43

Criminal behavior

Arrested

Incarcerated

92 30

61 31

Drug abuse treatment 52 29 56 31

TOPSb

1979-81

Pre Post

% %

29 9

68 38

90 55

68 43

71 47

KEY: *Black and white males; a

n = 966; bn = 405

Clients in TOPS had a slightly higher percentage of incarcerations than

those in DARP during the year before admission. This may reflect less

tolerance over time on the part of the criminal justice system in dealing

with substance abusers who engage in criminal behavior after leaving

drug abuse treatment programs. Table 3 also shows that arrest rates for

DARP clients dropped from 92 percent to 30 percent, and incarceration

rates fell from 61 percent to 31 percent. Alternatively, arrest rates for

TOPS clients dropped from 68 percent to 43 percent, and incarceration

rates fell from 71 percent to 47 percent. Clients in TOPS reported having

more incarcerations than arrests; this may be due to some clients spending

nights in jail without being charged with offenses.

88
Readmissions

About half of the clients were in drug treatment during the year before

joining DARP and TOPS programs. Slightly less than one-third were

readmitted to drug treatment programs during the year after they left TCs.

Thus, there was little difference between the percentage of clients who

received drug abuse treatment before joining or after leaving TCs in

1969-73 and in 1979-81.

CLIENTS IN TOPS RESIDENTIAL PROGRAMS

Table 4 presents characteristics of clients admitted to TOPS TCs and

other long-term residential programs. The figures for TCs differ slightly

between tables 3 and 4 due to the latter being based on a sample of 458

clients that included females, Hispanics, and other racial/ethnic groups.

Table 4 shows that clients who joined TCs were more likely to have been

non-Hispanic whites and to have had more drug-related problems during

the year before admission than clients who joined other programs.

Otherwise, there was little difference between admissions to these

programs in terms of demographic characteristics, prior drug abuse

treatment, criminal behavior, or psychological or social problems, which

provides an opportunity to assess the effects of different types of

programs on the outcomes of similar types of clients.

Table 5 presents data on the seven variables selected to assess the

effectiveness of TCs and other residential programs on the outcomes of

clients. There was not much difference between clients on those

variables during the year before admission or the year after termination

from programs. A different picture emerges, however, when client

characteristics, substance use patterns, source of referral, and drug abuse

treatment variables are taken into account when analyzing client

outcomes from programs.

Predictors of Client Outcomes

Tables 6 and 7 show predictors of client outcomes from programs when

other variables were taken into account. Variables that failed to predict

outcomes were not included in the tables. The second column in table 6

shows predictors of heroin use among admissions to TCs. Starting at the

top of this column, it can be seen that marital status was the only

demographic variable that predicted heroin use. The odds of heroin use

89
TABLE 4. Characteristics of clients admitted to TOPS long-term

residential programs

Client Characteristics

Demographics

Male

Female

Therapeutic Other

Communitya Residentialb

% %

80 77

20 23

Black 28 43

Hispanic 10 3

White (Non-Hispanic) 61 54

Other 1

Under 18 years 9 2

18-25 years 45 51

Over 25 years 46 47

Prior drug abuse treatment 57 54

Criminal Behavior

Arrested

Incarcerated

Psychological and Social Problems

Suicidal thoughts or attempts

Referred by criminal justice system

Drug-related problems (3 or more)

KEY: an = 436; b

n = 295

67 62

71 70

43 42

41 34

71 51

for clients who were married were about one-quarter (.23) of those for

clients who were not married. The odds ratio for this variable was

significant at the .05 level of probability. The only client background

90
TABLE 5. Changes in clients admitted to TOPS long-term residential

programs

Client Outcomes

Heroin†

Cocaine† 

Marijuana†

Psychotherapeutics†

Heavy alcohol use

Employed full-time

Predatory crimes

Therapeutic Other

Community* Residentialb

Pre Post Pre Post

% % % %

30 12 31 15

31 18 25 12

71 47 63 51

56 23 49 26

40 30 40 37

14 22 11 18

63 34 63 43

KEY: an = 436; bn = 295; †daily or weekly use

variable that predicted heroin use was one of the indicators of predatory

criminal behavior.

Near the middle of the second column of table 6 are odds ratios of heroin

use for clients who had been engaged in various patterns of drug use

before admission to TOPS programs. These indicate that clients who

used heroin during the year before admission were more likely to

continue using heroin during the followup year than clients with the

following patterns: other narcotics, multiple nonnarcotics, and single

nonnarcotics. Near the bottom of tables 6 and 7 are odds ratios for the

number of months spent in TOPS programs. For example, the odds ratio

for this variable in the second column of table 6 indicates that the odds of

heroin use for clients who stayed in TCs for “X” number of months was

.94 of that for clients who left the program after “X-1” number of months.

Thus, for each month that clients stayed in the program, there was a

6-percent reduction in the odds of their using heroin during the followup

year.

Table 6 shows that the number of months spent in TCs was a predictor of

six of the seven outcomes. The outcome that time spent in treatment did

91
TABLE 6. Predictors of client outcomes from TOPS long-term therapeutic communitiesa
TABLE 7. Predictors of client outcomes from TOPS residential programs other than therapeutic

communitiesa
not predict was heavy alcohol use. Alternatively, table 7 shows that the

number of months spent in other long-term residential programs predicted

only one of the seven outcomes: psychotherapeutic drug use. Overall,

client demographic and background variables were neither strong nor

consistent predictors of their outcomes from programs. Although

subsequent time spent in drug abuse treatment programs was a fairly

consistent predictor across outcomes, this was taken into account to

adjust for its effect on client outcomes from programs.

DISCUSSION AND CONCLUSION

This research compared the characteristics and outcomes of clients who

were followed up from DARP and TOPS TCs. Some differences were

found between patterns of drug use and criminality and the distribution of

ages of clients who participated in the studies. Nevertheless, the

percentage of clients admitted to drug treatment programs during the year

before admission and during the followup year was similar for both

studies.

A comparison was done of the characteristics of clients followed up from

the TCs and other types of long-term residential programs that

participated in TOPS. This revealed that there was little difference

between these clients in terms of demographics, patterns of substance

abuse, prior admissions to drug treatment programs, criminal behavior,

employment, and two of the three indicators of psychological and social

problems. The only noteworthy differences were that clients in TCs were

more likely to have been non-Hispanic whites and to have had more

drug-related problems. Both of these variables were taken into account

when predicting client outcomes from programs.

This research found that the longer clients spent in TCs, the less likely

they were to use heroin, cocaine, marijuana, and psychotherapeutic drugs

and the more likely they were to be employed full-time and to have

committed no predatory crimes during the followup year. Overall, these

findings are consistent with those reported by other studies of client

outcomes from TCs (Bale et al. 1980; De Leon 1984; Simpson 1979).

No significant relationship was found between time spent in treatment

and six of the seven outcomes from the other residential programs that

participated in TOPS; this may be due to these programs having a shorter

average length of stay (4.75 months versus 6.50 months) than the TCs.

94
The variables found to predict length of stay in the latter programs have

been discussed elsewhere (Condelli, in press-a, in press-b).

No significant relationship was found between the number of months

spent in TCs and heavy alcohol use. One reason for this may be that the

data for TOPS were collected at a time when many TCs did not address

heavy alcohol use. It has only been recently that TCs have begun to

implement relapse prevention programs for drug and alcohol abuse

(Baker et al. 1989; Carroll and Ohanesian 1989). Thus, this research may

underestimate the capability of TCs with effective relapse prevention

programs to reduce drug and alcohol use.

Time spent in treatment is at best only a rough indicator of the program’s

effects on clients. There is a need to focus on treatment and program

variables to better understand why time spent in treatment predicts client

outcomes from programs. Demographic and background variables, drug

use patterns, and sources of referral were not strong predictors of client

outcomes from programs. This also has been found to be the case for

predictors of retention in TCs (Condelli, this volume; Condelli and

Dunteman 1993) and predictors of retention in residential drug treatment

programs in general (Collins and Allison 1983).

More refined models need to be developed to better understand and

improve client outcomes from TCs. In order to develop these models,

research will need to: (1) focus more on clients with particular types of

problems (e.g., heroin users, cocaine users) than on all clients admitted to

programs; (2) determine the optimal amount of time that clients should

spend at programs to address those problems; and (3) identify specific

kinds of services that are effective for resolving specific problems.

REFERENCES

Anglin, M.D., and Hser, Y. Treatment of drug abuse. In: Tonry, M., and

Wilson, J.Q., eds. Drugs and Crime. Chicago: University of Chicago

Press, 1990. pp. 393-460.

Baker, L.A.; Galea, R.P.; Lewis, B.F.; Paolantonio, P.; and TessierWoupio, D. Relapse prevention training for drug abusers. J Chem

Depend Treat 2:173-192, 1989.

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Bale, R.N.; Van Stone, W.W.; Kuldau, J.M.; Engelsing, T.M.J.; Elashoff,

R.M.; and Zarcone, V.P. Therapeutic communities vs. methadone

maintenance. A prospective study of narcotic addiction treatment:

Design and one year followup results. Arch Gen Psychiatry 37: 179-

193,1980.

Biase, D.V. “Daytop Miniversity.” Final report of project activities under

National Institute on Drug Abuse grant no. R-18-DA-03382, 1985.

Brecher, E.M. Licit and Illicit Drugs. Mount Vernon, NY: Consumers

Union, 1972.

Carroll, J.F.X., and Ohanesian, S. Relapse prevention in a drug-free

therapeutic community. J Chem Depend Treat 2:193-207, 1989.

Casriel, D. So Fair a House: The Story of Synanon. Englewood Cliffs,

NJ: Prentice-Hall, 1963.

Clark, W.B., and Midanik, L. Alcohol use and alcohol problems among

U.S. adults: Results of the 1979 national survey. Alcohol and Health:

Alcohol Consumption and Related Problems. National Institute on

Alcohol Abuse and Alcoholism Monograph 1. DHHS Pub. No.

(ADM)82-1190. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1982.

Collins, J.J., and Allison, M. Legal coercion and retention in drug abuse

treatment. Hosp Community Psychiatry 34:1145-1149, 1983.

Condelli, W.S. Client evaluations of therapeutic communities and

retention. In: De Leon, G., and Ziegenfuss, J.T., eds. Therapeutic

Communities for Addictions. Springfield, IL: Charles C. Thomas,

1986.

Condelli, W.S. External pressure and retention in a therapeutic

community. Int J Ther Communities 10:21-33, 1989.

Condelli, W.S. Research on client retention in therapeutic communities:

Status and recommendations for future research. In: Proceedings of

Therapeutic Communities of America Planning Conference, Chantilly,

VA, December 6-9, 1992, in press-a.

Condelli, W.S. Variable domains for understanding and improving

retention in therapeutic communities. Int J Addict, in press-b.

Condelli, W.S., and De Leon, G. Fixed and dynamic predictors of

retention in therapeutic communities. J Subst Abuse Treat 10:11-16,

1993.

Condelli, W.S., and Dunteman, G.A. Issues to consider when predicting

retention in therapeutic communities. J Psychoactive Drugs

25(3):239-244, 1993.

De Leon, G., ed. Phoenix House: Studies in a Therapeutic Community

(1968-73). New York: MSS Information Corp., 1974.

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De Leon, G. The Therapeutic Community: Study of Effectiveness.

National Institute on Drug Abuse Research Monograph. DHHS Pub.

No. (ADM)84-1286. Washington, DC: Supt. of Docs., U.S. Govt.

Print. Off., 1984.

De Leon, G.; Wexler, H.; and Jainchill, N. The therapeutic community:

Success and improvement rates 5 years after treatment. Int J Addict

17:703-747, 1982.

Ginzburg, H.M. Defensive research: The treatment outcome prospective

study. Ann N Y Acad Sci 311:265-269, 1978.

Hosmer, D.W., and Lemeshow, S. Applied Logistic Regression. New

York: Wiley, 1989.

Hubbard, R.L.; Bray, R.M.; Craddock, S.G.; Cavanaugh, E.R.;

Schlenger, W.E.; and Rachal, J.V. Issues in the assessment of multiple

drug use among drug treatment clients. In: Braude, M.C., and

Ginzburg, H.M., eds. Strategies for Research on the Interactions of

Drugs of Abuse. National Institute on Drug Abuse Research

Monograph 68. DHHS Pub. No. (ADM)86-1453. Washington DC:

Supt. of Docs., U.S. Govt. Print. Off., 1986.

Hubbard, R.L.; Marsden, M.E.; Cavanaugh, E.R.; Rachal, J.V.; and

Ginzburg, H.M. Role of drug-abuse treatment in limiting the spread of

AIDS. Rev Infect Dis 10:377-384, 1988.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh,

E.R.; and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press,

1989.

Sells, S.B., and Simpson, D.D., eds. The Effectiveness of Drug Abuse

Treatment. Cambridge, MA: Ballinger, 1976.

Simpson, D.D. The relation of time spent in drug abuse treatment to

posttreatment outcome. Am J Psychiatry 136:1449-1453, 1979.

Simpson, D.D. Treatment for drug abuse. Arch Gen Psychiatry 38:875-

880, 1981.

Simpson, D.D., and Sells, S.B. Evaluation of Drug Abuse Effectiveness:

Summary of the DARP Followup Research. National Institute on Drug

Abuse Research Report. DHHS Pub. No. (ADM)82-1194.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1982.

Volkman, R., and Cressey, D.R. Differential association and the

rehabilitation of drug addicts. Am J Social 69:129-142, 1966.

Yablonsky, L. Synanon: The Tunnel Back. Baltimore, MD: Penguin,

1965.

97
ACKNOWLEDGMENTS

This research was supported in part by NIDA contract 271-91-4306. We

are indebted to Dr. Frank Tims for helping to facilitate the research and to

Anne Theisen and Dr. George Dunteman, respectively, for creating

computer programs and providing methodological consultation.

AUTHORS

Ward S. Condelli, Ph.D.

Research Sociologist

Center for Social Research and Policy Analysis

Robert L. Hubbard, Ph.D.

Director

Substance Abuse Treatment Research Program

Research Triangle Institute

P.O. Box 12194

Research Triangle Park, NC 27709-2194

98
Retention in Therapeutic

Communities: Challenges for the

Nineties

Benjamin F. Lewis and Roy Ross

INTRODUCTION

Retention and its corollaries are naturally occurring, yet influenceable

phenomena in a variety of treatment environments. Retention in

programs of planned duration adds the critical element of a defined

endpoint that can provide a measurement guidepost. Therapeutic

communities (TCs) and other residential programs for drug and alcohol

abusers represent a major portion of such planned duration programs.

The majority of research studies have concluded that there is a positive

relationship between the length of stay (LOS) and successful outcome

(De Leon 1980, 1984a; De Leon et al. 1982). The longer an individual

stays in the TC, the greater the likelihood that elimination or substantial

reduction of drug-related behaviors will be achieved and sustained. This

chapter examines what is known about the retention phenomenon and

makes a case for a greater understanding of its workings, manifestations,

and implications.

The major goals of this chapter are to establish a framework for a

common language that provides more precise and universally applicable

definitions of retention phenomena, overview the existing TC-based and

other relevant studies of retention phenomena, and identify critical

concerns for the TC field that emerge from these findings.

Definition of Terms: A Common Language

An initial review of the retention literature reflects a major shortcoming.

With no established definition of terms, it is difficult to view critical

concepts in a way that permits researchers to achieve uniformity of

understanding and to compare findings across programs. Terms such as

“retention,” “ length of stay,” “time in treatment,” “completion,”

“graduation,” “attrition,” “dropout,” “splitee,” “discharge against medical

advice (AMA)” or “against staff advice (ASA),” and “expulsion” need to

99
be universally and operationally defined. The TC field often uses valueladen key terms. For example, the term “dropout” has many definitions:

for some it describes a treatment failure; for others it means an individual

who had substantially completed his or her personal treatment goals, but

not the program’s.

Retention. This concept is the key to understanding the interaction

between clients, staff, program goals, and life events as they relate to time

in treatment. Retention is particularly important because the tension

between staying in treatment and leaving is at the very core of the TC

experience. Long-term residency requirements and a rigorous and

confrontational setting virtually guarantee that not everyone will stay to

completion; it is expected that some of those admitted will leave for

various reasons and at various personal and clinical junctures during

treatment.

The term “retention” is commonly used by clinicians and administrators

to describe the ratio between days in treatment and completion or

graduation. To the extent that retention approaches completion, it is

viewed as positive, with the highest value being placed on completion.

To the extent that retention falls short of completion, it is viewed as

negative and as a shortcoming of the client or program. However, this

view does not permit legitimate exploration of retention from other

perspectives, nor does it permit full investigation of the many forces that

interact with time.

Length of Stay. LOS, or days in treatment, is the most objective

measurement of retention; it refers to the number of days that clients

remain in treatment.

Completion. In general, completion describes a fixed time when formal

treatment ends and toward which retention efforts are aimed. If there

were no generally accepted date (or period) for program completion, the

concept of retention could be altered radically. Indefinite stays are

unacceptable; clients, other consumers, staff, and third-party payors must

have a legitimate timeframe to organize resources, plan clinical

interventions, and place significant others on hold.

However, another view of completion describes an undefined point in

time when a client substantially attains the identified and individual goals

of their treatment plan. From the client’s view, they are done. From the

program’s view, that client may be a dropout with all the attributes of that

100
role. This view reflects a significant departure from the traditional

definition of retention because it views treatment duration from the

client’s perspective and raises the question as to how to exploit this

perspective in a way that minimizes dropout.

Time in Treatment (Time in Program). This ambiguous term is often

used synonymously with LOS. It is variably reported in studies as

number of days, weeks, or months in treatment. However, the term is

also used to describe what happens during treatment. The concept of

“density,” “treatment delivered,” or “treatment life-space” adds the

dimension of the interaction of time with the program to the strictly

temporal and linear concept of time in treatment.

Attrition. In general, attrition refers to a gradual reduction over time

based on voluntary departures. In TC retention studies, attrition is often

synonymous with dropout. To the extent that attrition approaches

admission, it is viewed as negative.

Dropout. Dropout is usually studied in the context of treating chronic

conditions that require prolonged treatment. The perspective most often

used is the therapist’s or program’s, since dropout is defined in relation to

their idea of the optimal treatment duration. As applied to TCs, dropout

can refer to a client who is expelled because of lack of cooperation or a

poor attitude about treatment. Dropping out may be a manifestation of

dissatisfaction, unsuitability of the client or the program, lack of

motivation, acting out against coercion, or an expression of anger. In

TCs, the term “splitee” refers to two types of program dropouts: those

who are discharged for disciplinary reasons and those who leave the

program AMA or ASA.

Studies of dropouts have rarely attempted to distinguish among their

reasons for leaving. Client and staff perspectives on dropouts differ, and

a third view of dropouts further complicates the matter. From the

perspective of payors and funding agencies, dropouts represent a waste of

scarce resources and call into question the cost-effectiveness of programs.

Future retention research should explore more functional definitions of

dropouts according to reasons for leaving.

101
RETENTION STUDIES

Background

With respect to retention, TCs are not substantially different from other

modalities that treat substance abusers. Even given the variance in

program types, planned duration, and philosophy, substantial attrition

rates are evident for detoxification programs, methadone services (Joe et

al. 1980), drug-free outpatient programs, residential treatment (De Leon

and Schwartz 1984), Alcoholics Anonymous/Narcotics Anonymous

(AA/NA) fellowships, and other related drug abuse modalities.

Who leaves is important knowledge: If profiles could be developed

for early (or late) leavers, then dropout predictions could be made and

special attention paid to at-risk clients.

When people leave is important: Programs could develop and target

strategies that engage clients.

Why people leave is critically important: This knowledge gives

programs clues about how to modify their service delivery to increase

retention.

Overview of Retention Research

For the most part, the effectiveness of TCs has been evaluated through

posttreatment followup studies that have almost universally demonstrated

significant improvement over pretreatment status (De Leon 1984b;

De Leon and Jainchill 1981; De Leon et al. 1979). Client characteristics

associated with positive outcome have been identified, such as lower

lifetime criminality, higher pretreatment educational levels, lower drug

use levels, and higher employment (De Leon 1983a). While significant,

these effects are small when compared to the effects of time in treatment

(De Leon 1988).

Retention is important because research has established a firm

relationship between time spent in treatment and successful outcome

(Bale et al. 1980; De Leon and Schwartz 1984; Simpson 1981; Sugarman

1975). However, client factors in general are not strong predictors of

retention. Researchers have explored a variety of potential predictors,

focusing on demographic and psychometric variables, but no client

profile has emerged that reliably predicts LOS. Multivariate studies that

use composite measures of success in relation to LOS identify time in

treatment as the most consistent predictor of positive outcome, even when

102
the contribution of other client-related variables is removed (De Leon

1984c; De Leon and Andrews 1978; Holland 1983). Retention rates have

been described in considerable detail (De Leon and Schwartz 1984;

Glaser 1974; Sansone 1980).

With respect to attrition, high dropout rates are the rule for all drug

treatment modalities. In TCs studied, 1-year retention rates range from

10 to 30 percent. Findings indicate that the dropout rate is highest

(ranging between 30 to 40 percent) within the first 30 days of admission

(De Leon and Rosenthal 1979), with 30 percent reported within the first

2 weeks (De Leon and Schwartz 1984). The rate declines sharply as

clients stay in treatment longer, with the likelihood of dropout decreasing

with LOS itself (De Leon and Schwartz 1984). It is generally believed

that 3 to 6 months of treatment may be minimal for successful outcomes.

However, since the highest dropout rate occurs earliest in treatment, most

clients leave programs before being exposed to the cumulative effects of

TC methods.

Studies that have examined the differences in outcome between clients

who complete treatment (graduates) and those who drop out indicate that

those who graduate perform significantly better than dropouts on all

outcome measures (De Leon 1988). Among dropouts, however, there is

a positive relationship between outcome and LOS (De Leon 1984b;

De Leon et al. 1973; Holland 1983); the most impressive findings have

shown sustained improvement 5 years after treatment based on LOS.

Past studies have looked at changes in client populations over time. Such

studies should be repeated to examine changes in drug use trends, social

pathology, shifts in service utilization by different minority groups or

groups previously underserved (such as pregnant addicts), and the

impact of human immunodeficiency virus (HIV) and acquired

immunodeficiency syndrome (AIDS).

In their landmark review of retention, Baekeland and Lundwall (1975)

examined dropping out of treatment through the mid-1970s. They

identified 15 factors that predicted 75 to 100 percent of dropouts across a

variety of treatment modalities, settings, and therapies. Most of the

factors are relevant to TCs today in that they address the who, when, and

why questions from program and client perspectives. The factors

identified were: (1) social isolation/unaffiliation, (2) therapist attitudes

and behaviors, (3) discrepancies between patient and therapist treatment

expectations, (4) passive-aggressive behavior, (5) family attitudes and

103
behavior, (6) motivation, (7) behavioral and perceptual dependency,

(8) denial, (9) symptom levels and symptom relief, (10) sociopathic

features, (11) socioeconomic status, (12) age, (13) sex, (14) social

stability, and (15) drug dependence. The articulation of these factors

continues to provide a rich research agenda for retention studies.

The present review of studies is organized around two focuses that best

reflect available knowledge and existing gaps: pretreatment factors and

within treatment factors. In the future, treatment duration may be driven

by utilization review criteria, and third-party payors may become a more

significant factor.

Pretreatment Factors

Most of the dropout studies have focused on one or more of the following

in relation to LOS: (1) demographic characteristics (age, sex,

race/ethnicity); (2) primary drug use; (3) previous treatment history;

(4) immediate pretreatment status; (5) family background; (6) social

relations; (7) criminal background; and (8) psychological status. These

variables are the easiest to gather data on, particularly across programs,

and have the most standardized measures. Consideration of coercion and

motivation also fall within the pretreatment domain, but these variables

have been researched only recently.

Successful program completion also has been associated with family

participation and with the development of a social support system.

Findings suggest that improved preadmission procedures, better

assessment of motivation, willingness to comply with the program, and

family orientation may impact positively on retention. These factors have

been problematic for many traditional TCs, which stress internal

characteristics rather than community or family social support networks.

Race/Ethnicity

Previous TC studies have identified few major relationships between

race/ethnicity and retention, although Hispanics were found to have

significantly shorter LOS (De Leon 1983b), and African Americans were

more likely than whites or Hispanics to be retained in programs (Wexler

and De Leon 1977). One study found no significant differences between

majority and minority groups, although African Americans had

significantly less time in treatment than whites in situations in which the

majority of clients were white (Brown et al. 1985a). Another study

104
indicated that retention rates for African Americans were higher than

those observed for whites (Sansone 1980). Linguistic differences may

relate to retention more often than race/ethnicity.

Sex

With respect to gender differences in TC retention, it is clear that there

are universally lower retention rates for women. Males stay in treatment

significantly longer than females (De Leon and Jainchill 1981; Joe and

Simpson 1975; Sansone 1980). In one study, the cumulative proportion

of women in treatment began to drop off substantially at 10 weeks, and

the spread between men and women widened over time (Sansone 1980).

Generally, there have been no gender differences in outcome (De Leon

and Jainchill 1981; Greene and Ryser 1987; Sugarman 1975).

With respect to female clients who are court referred, it is postulated that

courts may be more lenient with females, coercing them less and

requiring less treatment tenure. Female attrition may be accounted for by

the observation that TCs generally are characterized by a male-dominated

orientation with little provision for the special needs of women. In order

to retain female clients, it has been suggested that treatment programs

should intensify their childcare and family services.

History of Previous Treatments

A history of previous treatment has been found to be positively related to

treatment outcome (Joe and Simpson 1975). Slightly higher retention

rates were found for readmissions, regardless of other demographic

differences (Sansone 1980). This raises the question as to whether

repeated doses of treatment are more effective than single episodes and

suggests a need for further analyses of existing and new data.

Primary Drugs

Most studies have not found significant differences in retention by type of

drug used (De Leon 1984b). However, the majority of TC retention

studies were undertaken while the abuse of opiates was preeminent.

Cocaine use in its various forms may have a different natural history that

may impact retention. Cocaine addicts may experience certain

physiological and psychological changes in the first 3 months after

withdrawal that may make cravings more problematic. There needs to be

105
further investigation of the sequelae of drug withdrawal and cravings and

their impact on attrition.

Age

Although there have been inconsistent findings, it is generally believed

that age is not significantly related to retention or to outcome (Sansone

1980). However, some findings indicate that clients in the middle age

range had more successes. The least favorable outcomes were more

frequent among the youngest clients. Other studies reflect higher attrition

among adolescents, who are seen as less likely to persevere in TC

treatment because of resistance to authority or because the juvenile justice

system is less willing to exert pressure than the adult criminal justice

system. Alternatively, higher retention has been found among younger

clients with strong pressure from significant others.

Legal Referral

The history of treatment for addicts reflects the interaction of coercive

treatment on retention and outcome. There is some evidence that

treatment completion and short-term outcomes were higher for adult

involuntary patients. Some early findings point to better outcome after

involuntary treatment and found that LOS was associated with lengthy

abstinence.

TC admissions reflect high proportions of clients with legal referral

backgrounds and coercion factors of varying degrees (De Leon 1988).

Drug Abuse Reporting Program (DARP) analyses reflected that

pretreatment legal pressures were not significantly related to retention,

that time in treatment did not differ between voluntary and legally

referred clients, and that longer retention predicted better outcomes (Joe

and Simpson 1975). Across other studies, there are considerable

inconsistencies in findings. Some studies have found that legally referred

clients remain longer in TCs than voluntary admissions (Collins and

Allison 1983; Hubbard et al. 1989; Sheffet et al. 1980). Several other

studies (Aron and Daily 1976; Condelli 1989; De Leon et al. 1979;

Sugarman 1975) have found TC retention to be associated with pressure

or legal status. Some studies have found this effect to be strongest in

early treatment: Self-referred clients may be insufficiently motivated to

stay, and higher retention rates of court referred clients may be due to a

disinclination to be institutionalized in a more restrictive environment

(Condelli 1989; De Leon et al. 1979; Sugarman 1975). However, other

106
studies have not found this association (Hartford et al. 1976; Joe and

Simpson 1975; Rinella 1976; Sansone 1980; Wexler and De Leon 1977).

In addition, other types of external pressure may be just as powerful, such

as anticipated or actual threats of placement of children or familial

pressure.

On the whole, the main findings suggest a complex relationship between

external pressure or legal referral and treatment outcome. There is an

enhancing effect between legal referral and outcome that appears to be

mediated through retention in treatment. There also is a suggestion of an

age, legal referral, and retention interaction (De Leon 1988).

Psychopathology

The best single predictor of both psychological and behavioral outcomes

is retention in treatment (De Leon 1984b; De Leon and Jainchill 1981).

In one study, all measures of the relationship between psychopathology

and treatment improvement showed a strong and positive relationship

between treatment duration and improvement. Another study found that

initial psychological scores are not predictors of retention or posttreatment outcome (Craig 1984a; De Leon 1983c, 1984c ). There is some

evidence that clients who exhibit greater psychological disturbance,

particularly depression, are more likely to leave treatment early (Sacks

and Levy 1979; Wexler and De Leon 1977). Some studies have found

that retention may be positively related to anxiety or less defensiveness

and less denial of problems (De Leon 1983c ). One study found that

clients who viewed their addiction as a sickness dropped out early,

possibly indicating that they may not be taking responsibility for their

drug-taking behaviors.

Psychological improvement in treatment predicts continued stay in

treatment (De Leon 1980; Wexler and De Leon 1977). Individuals who

improved within the first several months after admission showed a

significantly greater likelihood of continuing their stay in treatment

(De Leon 1980). Conversely, severe psychopathology is associated with

early dropout (De Leon et al. 1973; Sacks and Levy 1979).

Motivation

Given what is known about pretreatment variables such as demographics,

drug use, employment, and their relationship to retention, it is clear that

other client and program factors require investigation. Conventional

107
wisdom has always suggested that motivation and readiness for treatment

were the sine qua non of retention and success and has viewed dropout as

due to lack of motivation. Research that looks at the circumstances that

drive clients to treatment (extrinsic pressures), the client’s own inner

reasons (intrinsic pressures), the individual’s perceived need for services

(motivation), and the appropriate match between client need and

treatment modality (suitability) has established the foundation of these

critical dynamics. Others researching psychotherapy studies with

substance abusers and other populations have found motivation for

treatment to be the best predictor of outcome.

Motivation, readiness, and suitability appear to be more significant than

external pressure in terms of correlates of retention to 150 days. Client

perception of the severity of their problems, need for treatment, and

acceptance of the TC as appropriate treatment appears to relate to LOS.

Within Treatment Variables

Within treatment variables can be organized into (1) program

characteristics such as size, location, physical plant, staff, organizational

structure, and goals; (2) treatment events such as staff turnover, client

purges, and major program change; and (3) cognitive appraisal. Some

interactions may exist between client problems, program quality, and the

actions taken to address these problems. The relationship between within

treatment activities and time in treatment needs to be interpreted in the

context of the treatment services, staff actions, and client satisfaction. A

few studies have investigated the effects of treatment delivery variables

(Baekeland and Lundwall 1975), staff/therapist absences (Craig et al.

1982), the social climate of drug-free programs (Friedman et al. 1986a),

and program structural characteristics on client retention. In addition, the

relationship between staff turnover and client retention is a complex

dynamic that needs to be explored more fully (Orsini 1991; Sansone

1980). Although previous studies have not found that treatment program

variables predict retention, many investigators have felt they were worthy

of further investigation (De Leon 1984a; De Leon and Rosenthal 1979;

Heit and Pompi 1977; Sansone 1980).

Attitudes such as treatment appraisal and satisfaction may influence

treatment tenure (Joe and Friend 1989; Lewis 1986). In some studies,

client’s reasons for dropout were distributed equally between program

reactive and personal reasons, with significantly fewer personal reasons

associated with dropout after 12 months in treatment (De Leon 1984c ). It

108
has been postulated that aspects of the treatment environment, including

the way clients perceive they have been treated, may have powerful

effects on retention (Orsini 1991). While successful followup status and

LOS significantly relate to satisfaction with treatment (De Leon 1984a),

individual and composite measures of environmental openness,

individualized treatment, perceived rights, and treatment delivery need to

be developed to qualitatively characterize different programs in order to

understand outcomes better. More specific interactions between

satisfaction with key elements of treatment (e.g., individualized treatment

planning, perceived dignified treatment, perception of rights, and specific

satisfactions and dissatisfactions) also need to be investigated.

Limitations of Findings

A review of the literature suggests that reliable predictors of

retention/attrition have not been identified because of common

methodological limitations, including study-specific results and failure to

deal with the complex relationships among variables such as individual

characteristics, program goals and methods, and life-space events (Bale et

al. 1980; Craig 1984a, 1984b; Craig et al. 1982).

Many findings may be limited in external validity based on differences in

programs as defined or delivered (Allison and Hubbard 1985; Sheffet et

al. 1980; Winick 1980), lack of controls, client self-selection,

methodological deficiencies, differences in followup procedures,

additional treatment and nontreatment influences, changes in social

climate, validation of self-report, and changes in the TC field’s view of

the recovery continuum.

A multivariate approach using a large sample of programs with welldescribed qualitative dimensions is essential. Some investigators have

argued that treatment effectiveness cannot be validated without an

analysis of the strength and integrity of the treatment, and they have

suggested ethnographic studies to achieve a clearer understanding of the

treatment process.

The settings for most of the retention studies were traditional long-term

TCs of the seventies and early eighties that reflected homogeneous

treatment philosophies and methods. With the evolution of TCs along

planned duration and program lines, it is unclear whether the knowledge

gained from the previous studies of client characteristics is applicable to

the programs of the nineties.

109
RECOMMENDATIONS AND CRlTlCAL CONCERNS

TCs have been studied for nearly 20 years. Although the data are

frequently contradictory, one key finding has almost universal support:

Treatment outcomes improve as time in treatment increases.

Improvement in retention is to be encouraged, and the means to research

and achieve this goal should be supported. At face value this is a simple

enough proposition, but on closer examination its ramifications are

complex. Is improved retention desirable, or is there a point when

negative repercussions outweigh the benefits of this improvement?

Any change in retention or attrition will impact directly on treatment

capacity and must, in turn, impact on waiting lists. Unless treatment slots

are increased, improved retention will reduce the numbers of clients

exposed to treatment and increase the number of clients waiting to be

treated. What are the implications of this? First, longer waiting lists run

directly counter to the recent Federal initiative to reduce waiting lists.

Second, delaying the start of treatment carries attendant risks such as

contracting or spreading HIV infection, loss of motivation to seek

treatment, or continued criminal behavior. Reducing the number of

clients treated conveys a clear and troublesome message: Society is

placing a premium on a few more recovered clients at the expense of a

greater number of less recovered people.

Another paradox is that in an attempt to survive organizationally, TCs

admit clients whom their clinical experience tells them will leave early

(perhaps in the hope they will be wrong). When these clients do leave

early, their departure is rationalized as weeding out those who are

unready or unsuitable for the TC modality.

If the tension between remaining in treatment and leaving is a crucial

ingredient in TCs, then it must be acknowledged that some level of

attrition is not only inevitable but deliberate. Dropout rates may have less

to do with program insensitivity, low client motivation, staff frustration,

or the dozens of other factors identified in the literature, than with a

treatment modality whose renewal and vitality require the loss of a

certain proportion of its clients. The retention debate also brings into

sharp focus two different theoretical models of addiction: (1) the

enlightenment model, which attempts to change the whole person; and

(2) the compensatory model, which accepts the reality of lapses and trains

clients to use them in their recovery.

110
Multiple constituencies or perspectives will be affected by changes in

retention patterns: the treatment provider, the payor, the client, and the

staff. It is not certain that these constituencies have the same priorities or

needs regarding retention. From the perspective of the treatment provider

and staff, retention is a measure of clinical efficacy and revenue; from the

perspective of the payor, retention is a key index of cost-effectiveness;

and from the perspective of the client, retention is presumed to be an

index of satisfaction. What needs to be determined is whether

improvements in retention will serve each of the constituencies

appropriately; that is, whether they each want better retention and

whether treatment providers have the resources to deliver it. Whether

these different perspectives can be reconciled is a matter for continuing

discussion at the highest levels.

Other recommendations for research include the following:

1. Studies of the relationship of the treatment tenure of minorities in

majority-dominated programs and where minority status is not

represented in clinical staff or administration are needed.

2. Comparison and evaluation of different approaches to increasing the

retention of women with children are needed, including having

children live in, visit daily, or allowing visits in the natural

environment.

3. Investigation of the effects of repeated doses of treatment on retention

are necessary to determine whether there is a cumulative effect or an

optimal level of treatment episodes that predicts retention.

4. Further research is needed to examine the relationship of stages or

levels of client motivation or coercion on retention, including the

development of standardized measures of motivation.

5. Studies of the impact of developing therapeutic relationships between

staff and clients and the efficacy of individualized treatment planning

on retention and subsequent outcomes are needed. Since

individualized treatment planning is time- and cost-intensive, and

historically the program and not individual counseling has reflected

TC methods, this is a critical question to address.

6. Further studies are needed to determine the relationship between

treatment processes and retention, other within treatment variables,

111
and client satisfaction with key aspects of the treatment experience

such as perceived respect and dignity.

7. Well-controlled studies are needed to more precisely define the

effects of various levels of legal system pressure, pressures from

other social welfare system components, and pressure from

significant others on the retention phenomenon.

This chapter has presented recommendations from research to improve

retention and reduce attrition. These range from shorter treatment

periods, better matching of client to modality, and increased family

involvement. Generally, these recommendations will require either

reallocated or additional resources. The delicate economies of TCs are

already stretched to the limit with responsibilities to feed, shelter, treat,

educate, and rehabilitate. In the last several years, the HIV epidemic has

added the imperative to admit, treat, and educate drug addicts to reduce

HIV infection. Increased retention, no matter how desirable, may simply

be beyond reach. Although payors are demanding better retention, are

they prepared to pay for it? What tradeoffs are necessary to achieve it?

The goal of new research should be to ascertain the optimum balance

between retention and attrition. In doing so, it must be recognized that

the needs of the modality, the clients, and the funding agencies that

support it may not be in harmony. The central challenge for the TC field

in the future is to balance these competing priorities in a way that is

humane and cost-effective.

ACKNOWLEDGMENTS

This work was supported in part by the following National Institute on

Drug Abuse grants: R01-DA-04508, R01-DA-06151, and R01-DA05615. Karen C. Orsini also is gratefully acknowledged for her

contribution to this work.

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AUTHORS

Benjamin F. Lewis, Ed.D.

Senior Research Fellow

and

Codirector

AIDS Research Unit

School of Public Health

University of Massachusetts at Amherst

Amherst, MA 01003

Roy Ross, M.A.

President

Spectrum Addiction Services, Inc.

106 East Main Sreet

Westboro, MA 01581

116
Predictors of Retention in

Therapeutic Communities

Ward S. Condelli

INTRODUCTION

Reviews of the literature indicate that research has produced inconsistent

findings about the role that key variables play in client retention in

therapeutic communities (TCs) and other types of residential drug

treatment programs. A comparison of findings from the three largest

U.S. studies shows that there is little overlap between predictors of

retention (Collins and Allison 1983; Condelli and De Leon 1993; Joe and

Simpson 1976). This chapter discusses the conceptual and

methodological issues that need to be addressed if research is to be more

useful for understanding and improving retention in TCs.

RESEARCH ON RETENTION

Two large studies assessed the effects that time spent in treatment had on

TCs (Condelli and Hubbard, this volume; Simpson 1979). Both studies

found that clients who stayed in programs for long periods of time had

significantly lower rates of drug use, unemployment, and criminal

behavior than clients who stayed in programs for short periods of time

(Condelli and Hubbard, this volume; Simpson 1979). While there is

considerable variation in retention rates across programs (Condelli 1986;

De Leon 1991; De Leon and Schwartz 1984; Pompi and Resnick 1987),

overall only half of the clients who come to TCs stay as long as 3 months

(Simpson 1981). This threshold is critical because clients need to spend

at least 3 months in treatment before they begin to realize significant

improvements in their outcomes (Bale et al. 1980; Simpson 1981).

During the past two decades, the National Institute on Drug Abuse

(NIDA) has sponsored three large studies of retention in TCs and other

types of residential treatment programs. At the same time, NIDA has

funded multiple smaller studies of retention at TCs. Additional studies

have been conducted by researchers who received varying levels of

support from programs. Unfortunately, much of this research did not

reach its full potential for understanding and improving retention in TCs,

117
because this research produced inconsistent findings about the role that

key variables played in retention (Condelli 1986; Condelli and Dunteman

1993; Craig 1987). Furthermore, most of the variables reported to be

correlated or associated with retention were not found to be statistically

significant when analyzed within a multiple regression framework.

CONCEPTUAL AND METHODOLOGICAL ISSUES

Many of the inconsistent findings reported in the literature may have been

due to inappropriate comparisons among different kinds of clients and

programs. For instance, some reviews lumped studies conducted on drug

abusers together with studies conducted on alcoholics, the mentally ill,

and patients with various kinds of physical disorders. No research was

found in the literature that showed it was valid to group such

heterogeneous types of clients and programs together.

A related issue is the all too common practice of reviewing research at

different types of drug abuse treatment programs as if these programs and

their clients were interchangeable with one another. Such reviews cite

research done at methadone maintenance programs, TCs, and outpatient

drug-free programs, then attempt to generalize research findings to “drug

treatment programs.” This unit of analysis does not correspond to the

actual treatment received by any client. Therefore, this practice is

unlikely to be helpful for understanding or improving retention because

each client is treated at a specific type of treatment program and because

clients drop out of different programs for different reasons.

NIDA’s Manual for Drug Abuse Treatment Program Self-Evaluation

(Guess and Tuchfield 1977) on evaluating drug abuse treatment programs

states that: “Programs, clinics, and agencies with different goals,

objectives, and activities cannot legitimately be compared even on the

same measures.” The validity of this statement is supported by research

that found not only that different drug abuse treatment modalities (e.g.,

outpatient methadone maintenance, residential, outpatient drug-free)

attract different kinds of drug users but also that rates and predictors of

retention vary by type of modality (Collins and Allison 1983; Hubbard

et al. 1989). Hence, there are neither conceptual nor methodological

grounds for treating different types of drug treatment clients and

modalities as if they were interchangeable with one another. This

118
practice probably accounts for a considerable amount of the disagreement

in findings in the literature on retention in drug abuse treatment

programs.

Reviews of the literature rarely have taken into account differences

between therapeutic regimens within treatment modalities that have been

found to affect client retention. For example, studies have shown that

traditional TCs have lower rates of retention than modified and short-term

TCs (Condelli 1986; Joe and Simpson 1976). These findings suggest that

the duration and rigor of the therapeutic regimen are important factors in

client retention.

Reviews of the literature also indicate that there have been inconsistent

findings reported about the role key variables play in retention at TCs.

This raises the issue of which research findings should be given the

greatest weight. Much of this research consists of reports of variables

found to be correlated or associated with retention. While studies usually

report the statistical significance of relationships between variables, they

seldom report the strength of the relationships. Fewer studies yet report

the significance and strength of predictors when other variables that affect

retention are taken into account. Multivariate analysis is preferable to

bivariate analysis because it screens out large numbers of weak and

redundant variables; thus, it helps to clarify which variables have the

strongest and most reliable effects on retention.

THE THREE LARGEST RETENTION STUDIES

The conceptual and methodological issues discussed above have hindered

the drug abuse treatment field in identifying variables that are useful for

understanding and improving client retention. Consequently, a

comparison was done of the variables found to predict retention in the

three largest studies of TCs. This research was based on data collected for

the Drug Abuse Reporting Program (DARP) (Joe and Simpson 1976), a

demonstration project sponsored by Therapeutic Communities of

America (TCA) (Condelli and De Leon 1993; De Leon 1980), and the

Treatment Outcome Prospective Study (TOPS) (Hubbard et al. 1989).

The rationale for focusing on these studies is they included a large

number of subjects in programs located in different regions of the

country, and they used multivariate regression analysis to identify

predictors of retention.

119
The DARP study classified TCs according to treatment length, regimen,

and philosophy and then assessed predictors of retention in three different

types of programs (Joe and Simpson 1976). “Traditional therapeutic

communities” were highly structured, long-term in duration (1 to 3

years), and placed high demands on residents. “Modified therapeutic

communities” were patterned after the traditional ones, but they were

shorter in duration (6 to 9 months), placed fewer demands on residents,

and put more emphasis on learning practical skills. The findings

presented below were based on predictors of retention in the nine

traditional TCs.

The TCA study focused on five programs described by their chief

executive officers as traditional long-term TCs in terms of treatment

philosophy, goals, structure, process, and staffing patterns (De Leon

1980). Although the focal point of the study was to develop a system for

collecting and analyzing data related to resident retention, the ultimate

goal was to increase the self-evaluation capacity of the programs. The

methodology used for this study has been described in detail elsewhere

(Condelli and De Leon 1993).

The TOPS study analyzed client retention in 17 residential treatment

programs: 10 of these were long-term traditional TCs, and the remainder

were a mixture of other types of residential programs (Collins and Allison

1983). TOPS was the only one of the studies that interviewed clients

while they were in the program. The research discussed here, however,

focused on client and admissions of retention in order to make it more

comparable to the findings from the DARP and TCA studies.

Predictors of Retention in Residential Programs

A table was constructed to compare DARP, TCA, and TOPS predictors

of retention (Condelli and Dunteman 1993). This table showed that the

client’s education was the only variable that predicted retention across the

three studies, and there was little overlap between predictors of retention

across the studies. One possible explanation for these findings is the time

differences when the studies were conducted: DARP focused on clients

admitted to programs in 1971-72, whereas the TCA and TOPS focused

on clients admitted to programs nearly a decade later. This explanation

does not account for differences between predictors in TCA and TOPS,

however, because these studies were conducted at about the same time.

120
Other possible explanations for inconsistent predictors of retention across

the three largest studies include differences in samples of programs,

variables taken into account, and measures of retention. While DARP

found that predictors of retention varied by type of TC, TOPS predicted

retention in a sample comprised of different types of residential programs.

Finally, although all of the studies focused mostly on client demographic

and background characteristics to predict retention, TCA and TOPS took

into account variables from other domains.

The same measures of retention were not used in the studies: DARP and

TOPS used the number of days that residents stayed in the program,

whereas TCA used a log to transform the length of stay to assure that it

met the assumptions of the statistics used to analyze the data (Condelli

and De Leon 1993). Lack of uniform measures and common

terminology has made it difficult to compare the results of retention

studies in the substance abuse treatment field (Lewis and Ross, this

volume).

Subsequent analysis was performed on data collected for TOPS to resolve

findings that were inconsistent with those reported by the other large

studies. This involved focusing on 10 traditional TCs, including

analyzing variables found to predict retention in the other two studies,

assessing the effects of variables in different domains, and comparing

predictors on the two measures of retention. The analysis of TOPS data

showed that predictors of retention differed somewhat according to the

sample of programs and domains of variables used. In addition, the

analysis revealed that the log measure of length of stay was more

sensitive to client and admissions variables than the number of days

stayed at the programs. Consequently, the log measure was used to

analyze predictors of retention. The procedures used to analyze these

data have been described elsewhere (Condelli and Dunteman 1993).

Predictors of Retention in Therapeutic Communities

Table 1 shows DARP, TCA, and TOPS predictors of retention in

traditional TCs. The left column displays variables that predicted

retention in at least one of the studies. The other columns provide

information on the samples, predictors, and overall results for the three

studies. An “X” marks variables that predicted retention, whereas a dash

denotes variables that did not. A blank indicates that the study did not

report assessing the effect of the variable on retention. Two figures are

displayed at the bottom of each column of the table: These are the

121
TABLE 1. DARP, TCA, and TOPS predictors of retention in traditional

therapeutic communities

Study DARP

Date of Admissions (1971-72)

Number of Programs 9

Sample Sizes 881

TCA TOPS

(1979) (1979-81)

5 10

802 1,800

Fixed Client Variables

Race/Ethnicity

Age

Family Responsibility

Education

Sister Had Alcohol Problem

Drug Use Sequence

Drug Use Patterns

Dynamic Client Variables

Comfortable in Large Groups

TC Staff Predictions

External Pressure Predictors

Legal Involvement

TASC Participation*

In Prison Before Admission

– –

Number of Predictors

X

X

X

X

4

X

X

X

X

X

X

6

X

X

X

X

X

X

6

Variance Explained 4%a

ll%b

5%b

KEY: *TASC = Treatment Alternatives to Street Crime; a = actual

number of days; b = log of number of days.

number of significant predictors of retention and the percentage of

variance explained by the predictors. A low percentage indicates that the

variables assessed by the study did not explain most of the factors that

resulted in clients leaving the program. Thus, when predictors explain

5 percent of the variance in retention, 95 percent of the variance in

retention is unexplained.

122
The predictors shown in table 1 were grouped according to whether they

were fixed or dynamic client variables (Condelli and De Leon 1993).

Fixed client variables are those that are difficult or impossible to change,

such as demography (e.g., race, ethnicity, gender, language, and age) and

history (e.g., prior employment and drug use patterns). Dynamic client

variables are those that presumably could be addressed by TCs, such as

feeling comfortable in large groups of people. Another dynamic variable

was predictions by TC staff as to whether clients would stay long enough

to benefit from the program. Table 1 also shows external pressure

variables that predicted retention. These included whether clients were

involved with the legal system, in a Treatment Alternatives to Street

Crime (TASC) program (Weinman 1990), or in prison before admission.

Table 1 illustrates that there are still some differences between DARP,

TCA, and TOPS that make it difficult to compare the results. These

studies were conducted on different samples of clients who were at

different programs at different times. They also assessed variables from

different domains and did not use the same variables to measure the same

dimensions. As a result, table 1 shows that there was little overlap

between predictors of retention in these studies. Indeed, client education

was the only variable that predicted retention across the three studies.

Note that all of the DARP predictors were concentrated in the fixed client

variable domain, whereas half or more of the TCA and TOPS predictors

were from the dynamic client and external pressure variable domains.

This may reflect changes that occurred in both the programs and clients

during the decade that elapsed between the studies. However, it is more

likely that the dynamic client and external pressure variables simply were

more powerful predictors of retention than the fixed client variables.

The lack of agreement between DARP and other studies with regard to

external pressure may have been due to historical factors. TCs were just

getting started in the late 1960s and had not been evaluated for

effectiveness. Consequently, it would have been unlikely that the legal

system would have exerted pressure on clients to join these programs.

Similarly, the first TASC programs came into existence in 1972

(Weinman 1990), the year after the last data were collected for the DARP

retention study.

Finally, table 1 shows that research using multivariate analysis on large

samples of clients still did not produce consistent findings about the role

that variables play in retention. This may be because this research

123
focused on weak predictors of retention: Many of these variables

probably would not have been statistically significant if they had not been

based on such large sample sizes. Since this research concentrated

primarily on fixed client variables, it suggests that there is a need to focus

on variables from other domains to better predict retention.

Predictors of Retention in Smaller Studies

In addition to the three large studies cited above, five smaller multivariate

studies (Condelli 1986, 1989; De Leon 1983; Sheffet et al. 1980;

Washbume and Condelli 1980) have been conducted on retention in

traditional TCs for substance abusers (Condelli, in press-a, in press-b).

These smaller studies may be limited in their findings in that two were

conducted at single programs, all of the studies were performed at

programs located in New York or New Jersey, and none of the studies

had large sample sizes. Nevertheless, this research has identified

variables that need to be taken into account by future studies of retention.

The fixed client predictors of retention in these studies included age,

race/ethnicity, parents’ socioeconomic status, drug use involvement and

pattern, employment history, local versus out-of-town residence, and

marital status (Condelli 1986, 1989; De Leon 1983; Sheffet et al. 1980;

Washburne and Condelli 1980). The dynamic client predictors included

drugs being important to one’s friends, self-esteem, self-concept, the

Minnesota Multiphasic Personality Inventory (MMPI) Dependency scale,

perceived happiness, and hopefulness about the future (De Leon 1983;

Sheffet et al. 1980; Washburne and Condelli 1980). Alternatively, the

external pressure predictors of retention included both legal and

significant other’s pressure (Condelli 1986, 1989; Sheffet et al. 1980).

The smaller studies also identified the following program and treatment

variables that predicted retention: (1) participation in a traditional as

opposed to a modified TC; (2) how many months clients felt they needed

to stay in the program; (3) how important it was to the staff that clients

stay in the program; and (4) how difficult clients found it to conform to

the behavior expected by the program (Condelli 1986, 1989). Other

predictors of retention were scales that compared residents’ evaluations of

their programs with their evaluations of their high schools on salience,

pleasure, and good-bad dimensions (Condelli 1989).

There was agreement among all the studies reviewed that fixed client

variables, by themselves, are not powerful predictors of retention in TCs.

124
However, some research suggests that fixed client variables may interact

with variables in other domains in ways that affect retention. For

example, one study found that race/ethnicity and substance abuse patterns

explained 10 percent of the variance in retention when MMPI

Dependency scale scores were taken into account (De Leon 1983).

Another study found that age explained 11 percent of the variance in

retention when external pressure, program, and treatment variables were

included as predictors (Condelli 1989). Overall, these findings indicate

that research needs to focus more on dynamic client, external pressure,

program, and treatment predictors, as well as on fixed client predictors, if

it is to be more useful for understanding and improving client retention.

REFERENCES

Bale, R.N.; Van Stone, W.W.; Kuldau, J.M.; Engelsing, T.M.J.; Elashoff,

R.M.; and Zarcone, V.P. Therapeutic communities vs. methadone

maintenance. A prospective study of narcotic addiction treatment:

Design and one-year followup results. Arch Gen Psychiatry 37:179-

193,1980.

Collins, J.J., and Allison, M.S. Legal coercion and retention in drug abuse

treatment. Hosp Community Psychiatry 34(12):1145-1149, 1983.

Condelli, W.S. Client evaluations of therapeutic communities and

retention. In: De Leon, G., and Ziegenfuss, J.T., eds. Therapeutic

Communities for Addictions. Springfield, IL: Charles C. Thomas,

1986. pp. 131-139.

Condelli, W.S. External pressure and retention in a therapeutic

community. Int J Ther Community 10(4):21-33, 1989.

Condelli, W.S. Research on client retention in therapeutic communities:

Status and recommendations for future research. In: Proceedings of

Therapeutic Communities of America Planning Conference, Chantilly,

VA, December 6-9, 1992, in press-a.

Condelli, W.S. Variable domains for understanding and improving

retention in therapeutic communities. Int J Addict, in press-b.

Condelli, W.S., and De Leon, G. Fixed and dynamic predictors of

retention in therapeutic communities. J Subst Abuse Treat 10: 11-16,

1993.

Condelli, W.S., and Dunteman, G.A. Issues to consider when predicting

retention in therapeutic communities. J Psychoactive Drugs

25(3):239-244, 1993.

Craig, R.J. Clinical Management of Substance Abuse Programs.

Springfield, IL: Charles C. Thomas, 1987.

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De Leon, G. “Therapeutic Communities: Training Self-Evaluation.” Final

report prepared for National Institute on Drug Abuse, 1980.

De Leon, G. “The Therapeutic Community: Predicting Retention and

Followup Status.” Report prepared for National Institute on Drug

Abuse, 1983.

De Leon, G. Retention in drug-free therapeutic communities. In: Pickens,

R.W.; Leukefeld, C.G.; and Schuster, C.R., eds. Improving Drug

Abuse Treatment. National Institute on Drug Abuse Research

Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 218-244.

De Leon, G., and Schwartz, S. The therapeutic community: What are the

retention rates? Am J Drug Alcohol Abuse 10:267-284, 1984.

Guess, L.L., and Tuchfield, B.S. Manual for Drug Abuse Treatment

Program Self-Evaluation. Treatment Program Monograph. DHEW

Pub. No. (ADM)79-422. Washington, DC: Supt. of Docs., U.S. Govt.

Print. Off., 1977.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh,

E.R.; and Ginzberg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press,

1989.

Joe, G.W., and Simpson, D.D. Retention in treatment of drug users

admitted to treatment during 1971-1972. In: Sells, S.B., and Simpson,

D.D., eds. The Effectiveness of Treatment of Drug Abuse Vol. IV.

Cambridge, MA: Ballinger, 1976.

Pompi, K.F., and Resnick, J. Retention of court-referred adolescents and

young adults in the therapeutic community. Am J Drug Alcohol Abuse

13:309-325, 1987.

Sheffet, A.M; Quinones, M.A.; Doyle, K.M.; Lavenhar, M.A.; Nakah,

A.E.; and Louria, D.B. Assessment of treatment outcomes in a drug

abuse rehabilitation network: Newark, New Jersey. Am J Drug

Alcohol Abuse 7(2):141-173, 1980.

Simpson, D.D. The relation of time spent in drug abuse treatment to

posttreatment outcome. Am J Psychiatry 136:1449-1453, 1979.

Simpson, D.D. Treatment for drug abuse. Arch Gen Psychiatry 38:875-

880, 1981.

Washburne, N.F., and Condelli, W.S. Path analysis of treatment

outcomes. In: Washbume, N.F., ed. Dynamics of Treatment in

Therapeutic Communities: Vol 1. Final report for National Institute on

Drug Abuse. Rutgers University at Newark: Department of Sociology,

1980.

126
Weinman, B.A. “Treatment alternatives to street crime (TASC).” In:

Inciardi, J.A., ed. Handbook of Drug Control in the United States.

New York: Greenwood Press, 1990.

ACKNOWLEDGMENTS

This research was supported in part by National Institute on Drug Abuse

grant 1-R01 DA-04847-01A1 and contract 271-91-4306.

AUTHOR

Ward S. Condelli, Ph.D.

Research Sociologist

Center for Social Research and Policy Analysis

Research Triangle Institute

P.O. Box 12194

Research Triangle Park, NC 27709-2194

127
Adolescents in Therapeutic

Communities: Retention and

Posttreatment Outcome

Kenneth F. Pompi

INTRODUCTION

This chapter reviews the literature, with the inclusion of some

unpublished data, to answer two questions: Are adolescents retained in

therapeutic community (TC) treatment? Do TCs produce successful

outcomes with adolescents; that is, do they reduce substance use and

crime and increase productive behavior?

This chapter reviews nine data sets to:

Compare treatment retention and outcome for adolescents with that

for older clients within the TC modality;

Compare treatment outcome for adolescents in TCs with adolescents

in other drug treatment modalities; and

Examine the relationship between outcome and time in program

(TIP).

The chapter does not compare the retention of adolescents in TCs with

the retention of adolescents in other modalities, as the comparison is

difficult to interpret.

Who is an adolescent? Standard psychology texts (e.g., Morris 1984;

Schiamberg 1985) state that adolescence is the time of transition between

childhood and adulthood beginning with puberty at about 11 or 12 years

of age. The end of adolescence with the assumption of adulthood is not

as well defined: The textbooks distinguish a period of “later adolescence”

or “young adulthood” spanning from age 17 or so to the middle or late

twenties.

128
Perhaps more appropriate is the legal definition of juvenile. Some State

agencies, such as the Department of Public Welfare in Pennsylvania, do

not license facilities where juveniles and adults are mixed. Therefore,

emerging all-adolescent programs (such as Abraxas Foundation) pay

more attention to the legal definition of juvenile than to the human

development theorists who have tried to define the period of adolescence.

In Pennsylvania, the legal definition of juvenile is:

. . . anyone under 18 years of age, with two exceptions: (1) those

who are past their 18th birthday but remain under the supervision

of the juvenile court (which can maintain jurisdiction until the

21st birthday) for an act committed before their 18th birthday;

and (2) those under 18 who were arrested for serious crimes and

certified as adults (Pompi and Resnick 1987, p. 311).1

In New York, the definition of juvenile has varied over the past 20 years

(De Leon 1984a). Whatever the definition of adolescent or juvenile,

however, the present analysis will have to be content with the age ranges

defined by the various studies reviewed.

Before presenting the studies, the following question is of interest: Do

adolescents currently comprise a robust minority of the TC population;

that is, does the topic for this review have any current import?

Table 1 presents data from a survey of the Therapeutic Communities of

America (TCA) membership in late 1988 and early 1989. Listed are

those TCs that responded to the survey and included population data in

their response. The column entitled “Percent Youth” shows the

percentage of the total population that was 20 years of age or younger for

each TC. As shown by the weighted mean at the bottom of this column,

19.1 percent, or about one in five clients, were youth. As shown at the

bottom of the column entitled “Total Youth,” youth in all surveyed TCs

totaled almost 8,000 clients. Therefore, this review does have current

import.

Findings from the nine studies that comprise this review are presented as

follows: Study parameters and sample characteristics, retention data, and

treatment outcome are summarized in tables 2, 3, and 4, respectively.

Only four of the nine studies reviewed followed up clients after discharge

and, therefore, permit an analysis of treatment outcome. These studies

are presented in table 4.

129
TABLE 1. Adolescents in therapeutic communities: Survey of the

membership of Therapeutic Communities of America in late

1988/early 1989
TABLE 2. Study parameters and sample characteristics
TABLE 2. Study parameters and sample characteristics (continued)
TABLE 3. Retention
TABLE 3. Retention (continued)
TABLE 4. Outcome: Pretreatment to posttreatment change
DARP

The Drug Abuse Reporting Program (DARP) of the Institute of

Behavioral Research at Texas Christian University was the first

comprehensive multimodality study of the drug abuse treatment industry.

This massive study was funded initially by the National Institute of

Mental Health (NIMH) and subsequently by the National Institute on

Drug Abuse (NIDA). In a chapter in Youth Drug Abuse, Sells and

Simpson (1979) presented a subset of the DARP data set for young

clients. Because DARP distinguished TCs from other modalities, the

youth sample for those treated in TCs can be examined.

The first column of table 2 refers to DARP. The DARP study evaluated

treatment programs in the late 1960s and early 1970s and involved 34

TCs. “Adolescents” or “youth” (these terms are used interchangeably in

this review) were defined for the study as those clients aged 19 and

younger. Approximately 32 percent, or about one-third, of the TC

population, were in this age range. The youth and adults were mixed in

the TCs; in fact, in only one of the data sets of this review were the

adolescents treated separately from the adults. As the DARP authors

point out:

The DARP treatments were not particularly oriented to youth as a

target population, but treated them along with older drug users in

the various programs (Sells and Simpson 1979, p. 609).

The TC youth sample for the retention analysis was large (1,222 clients),

but it was reduced to 238 clients for the outcome analysis. The TC youth

were 63 percent male and 71 percent white. The youth were primarily

opioid users. Referral data were not available independently for youth in

the DARP study; therefore, the percentage of youth who were referred by

the justice system is unknown.

Retention

The first column of table 3 applies to the DARP TC youth sample. The

median TIP for youth in TCs was found to be 96 days; a total of

26 percent, or about one-quarter of TC youth, dropped out of treatment

within the first month; only 15 percent of TC youth completed treatment.

The median TIP and completion percentage were used to compare youth

and adult retention; appreciable differences were not found. Therefore,

136
the early TCs make TCs’ diffculties in holding on to their clients

extended to their youth populations as well.

Outcome

The outcome for the DARP TC youth sample is presented in the first

column of table 4. The time period between admission to treatment and

the followup interview was 4 to 6 years. What is termed the

“pretreatment/posttreatment assessment window” in the table (the time

periods during which behavior was assessed) was 2 months before

admission and 2 months before the followup interview.

Outcome measures for this review are divided into three categories:

substance use, employment, and criminality. For substance use, four

classes are distinguished: opioid, nonopioid (cocaine, sedatives,

stimulants, psychedelics, and other illegal drugs), marijuana, and alcohol.

As indicated in table 4, there was a pretreatment to posttreatment decrease

in opioid and nonopioid use by the DARP TC youth. Marijuana,

however, showed a slight increase in use; alcohol use showed little

change. There was a pretreatment to posttreatment increase in measures

of employment (for DARP, defined as actual employment and related

activities), and a decrease in measures of criminality (defined as arrests

and support from illegal sources).

Summarizing the DARP outcomes for TC youth, a phrase that the authors

used in another context applies: The outcomes were “favorable, if not

impressive” (Sells and Simpson 1979, p. 610). The data presented in the

study do not permit a reliable comparison of how TC youth fared in

comparison with adults on outcome; an unpublished comparison

demonstrated no significant differences between these groups (Simpson,

personal communication, 1991).

A conclusion can be drawn from Sells and Simpson (1979) in regard to

the treatment of adolescents in TCs versus other treatment modalities.

For each modality, the author averaged pretreatment to posttreatment

improvements in the nine DARP criteria measures presented. The

average for TCs was better than the averages for methadone maintenance

programs, outpatient drug-free programs, detoxification, and an untreated

control group that went through intake but did not return for treatment.

A positive correlation between posttreatment outcome and TIP was found

for the youth sample (Simpson, personal communication, 1991). This

137
relationship, or TIP effect, strengthens the inference that treatment caused

the positive changes. Furthermore, as TC youth were found to do better

overall than youth in other modalities, the conclusion that the TCs were

responsible for the pretreatment to posttreatment improvement has further

support and merit.

Summary

Retention rates for DARP TC youth were similar to those for adults.

Positive outcomes were found for drug use other than marijuana and

alcohol; positive outcomes also were found for employment and

criminal involvement.

Averaging the outcomes revealed that TCs did better with adolescents

than other treatment approaches.

A TIP effect was found for TC youth in DARP.

The DARP study provides an excellent introduction to methodology and

baseline retention and outcome results for the analysis of subsequent data

sets.

PENNSYLVANIA

The single State authority for drug treatment programs in Pennsylvania

established the Uniform Data Collection System in the early 1970s to

monitor and evaluate drug and alcohol treatment. Rush (1979) used this

large data set to explore the treatment of adolescents. The era studied by

Rush was the mid-1970s (table 2, second column); the actual number of

TCs contributing data to the study was unavailable in the reference. For

the study, Rush distinguished clients 17 and younger from those 18 to 19

years of age; both groups of clients were used as the youth sample for the

present review (sample size = 961).

Comparing the first and second columns of table 2, the main contrast with

the DARP sample is that the Pennsylvania youth were not primarily

opioid users; by this time (the mid-1970s), the familiar pattern of

polydrug, nonopioid use associated with adolescents had appeared. A

large percentage (44 percent) of the youth were referred by the justice

system (i.e., under some form of legal pressure to be in treatment).

138
Retention

The median TIP was 35 days for TC youth in the Pennsylvania sample

(table 3, second column), which was much shorter than the DARP figure

of 96 days. There is no ready explanation for this difference. The other

retention indicators were not available in the reference.

The Pennsylvania reporting system obtained outcome criteria at

discharge, but followup data were not obtained. Therefore, outcome data

from the Pennsylvania study are not included in this review.

Summary

Adolescents in TCs in the mid-1970s, at least in Pennsylvania, were

primarily polydrug, nonopioid abusers.

The justice system was a primary referral source for Pennsylvania

TCs serving adolescents.

Retention in treatment was very low for the adolescents in the

Pennsylvania sample.

TOPS

The NIDA-funded Treatment Outcome Prospective Study (TOPS)

(Hubbard et al. 1989) of the Research Triangle Institute in North Carolina

is the next often-cited outcome study following DARP. In a NIDA

monograph entitled Treatment Services for Adolescent Substance

Abusers, Hubbard and colleagues (1985) reported on a youth sample of

clients from the TOPS database. TOPS distinguished between residential

and outpatient drug-free programs; the residential programs were almost

all TCs. The treatment era studied was about one decade after the DARP

era (table 2, third column); 14 TCs contributed data to the study.

Comparing the first three columns of table 2, the TOPS sample (sample

size = 402) parallels that of DARP and the Pennsylvania study with these

exceptions:

The percentage of the total TC population comprised of youth was

only 14 percent for TOPS as compared with 32 percent for DARP.

139
Unlike the DARP sample of about 10 years earlier, but like the

Pennsylvania sample of about 5 years earlier, pretreatment drug use

was primarily polydrug and nonopioid.

The TOPS authors discuss the first exception as follows:

. . . the programs in the TOPS sample seem somewhat less

oriented toward youth than drug treatment programs generally. It

should be noted, however, that TOPS specifically excluded

school-based programs and did not include any programs

designed principally for youth (Hubbard et al. 1985, p. 50).

The 40-percent justice system referral base for TOPS parallels that of the

Pennsylvania data set.

Retention

The first-month dropout rate was available in the reference, and other

retention data were provided by Hubbard (personal communication,

1991). Median TIP for the TC youth was 77 days (table 3, third column);

about one-third of the youth dropped out by the first month, and 1 out of

10 completed treatment. The youth and adult groups were found to

exhibit equivalent retention. These results roughly parallel the DARP

results presented earlier.

Outcome

The interval between the treatment and followup interview for TOPS was

1 year after discharge (table 4, second column), which was considerably

shorter than for DARP. The TOPS results parallel DARP for nonopioid

use, which showed a pretreatment to posttreatment decrease; unlike

DARP, marijuana and alcohol use also showed decreases. For the TOPS

adolescents, unlike the DARP adolescents, opioid use was minimal, so

outcome data for this drug class were not presented. Like DARP, youth

employment and criminality showed positive outcomes.

The TOPS data did not permit a reliable comparison of youth versus adult

outcomes. Like DARP, TC outcomes were somewhat better than

outpatient drug-free programs; as opioid use was low, there were few

adolescents in methadone maintenance programs for a comparison with

that modality. Like DARP, outcomes were positively correlated with

TIP.

140
Summary

The TOPS retention data for TC youth were similar to those of

DARP.

TOPS youth and adults exhibited equivalent retention.

Positive outcomes were found for three drug classes, employment,

and criminal involvement.

TCs did better than outpatient drug-free programs with adolescents.

A TIP effect was found for TC youth in TOPS.

However, the TOPS authors expressed the following cautions for the TC

adolescents: (1) One in four older youth reported posttreatment daily

marijuana use regardless of time in treatment, and (2) for those youth

who stayed in treatment 3 months or more, one in four reported

posttreatment heavy alcohol use.

Therefore, the authors concluded:

The results of available studies on drug treatment for youth,

however, are only moderately encouraging. Even though

intervention occurs early in the drug use career, many young

clients continue to abuse both alcohol and marijuana (Hubbard

et al. 1985, p. 63).

GATEWAY HOUSES

Having discussed three multimodality data sets developed by

investigators not affiliated with individual drug treatment programs,

studies of TC-based researchers now are addressed. These studies are

presented in roughly chronological order by treatment era. The most

appropriate reference for this review of the work of Holland with the

Gateway Houses program is her paper on the effectiveness of treatment

on criminal behavior (Holland 1978; see also Holland 1984 for a

comparison of drug use patterns and other problems of adolescents and

adults admitted to Gateway Houses).

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Holland (1978) studied the Gateway Houses treatment program in the late

1960s and early 1970s (table 2, fourth column), the same era as DARP.

Unlike the references cited for DARP, the Pennsylvania study, and

TOPS, Holland’s study did not focus on adolescents. However, since the

data were presented for a distribution of age ranges, it was possible to

discern retention and outcome data independently for a youth group. The

youth group defined for this review had age 18 as an upper limit, 1 year

lower than that of DARP, the Pennsylvania study, and TOPS. The

percentage of youth in the total TC population was close to that of the

DARP study; like the DARP, Pennsylvania, and TOPS studies, the youth

were mixed with the adults in the TC milieu. In contrast, however, the

youth sample available for analysis was small (sample size = 52). The

data presentation did not permit a determination of demographics or

referral circumstances independently for the youth. Because the study

focused on criminal behavior, information on drug use was not available

in the reference.

Retention

The only retention statistic available in the reference was the completion

rate (table 3, fourth column). As with DARP and TOPS, the completion

rate for Gateway Houses youth was low. The completion rates for adults

and youth were similar (18 percent versus 15 percent, respectively),

paralleling the results of DARP and TOPS.

Outcome

The followup and assessment time periods parallel TOPS (table 4, third

column). Because the study evaluated only criminal behavior, substance

use and employment data were unavailable. Youth criminality, as

indicated by arrest rate, decreased from a pretreatment baseline mean of

.65 arrests to a posttreatment mean of .37 arrests at followup, but this

decrease was not significant.

In contrast, pretreatment to posttreatment decreases in mean arrests for

two groups of adults were significant: .67 to .25 arrests for those aged 19

to 25, and 1.08 to .56 arrests for those aged 26 and older. Because this

was a study of a single TC, no comparison was possible with other

treatment modalities. Like DARP and TOPS, a TIP effect for the youth

group was found in the Gateway Houses study. In particular, the fraction

of the youth group who stayed in treatment 9 months or more showed a

substantial decrease in arrest rate.

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Summary

There was no appreciable difference in retention between Gateway

Houses youth and adults, which was similar to the results of DARP

and TOPS.

Youth did not profit as much as adults from the Gateway Houses

treatment experience in the reduction of criminality.

A TIP effect for arrest rate was found for the Gateway Houses youth.

ODYSSEY HOUSE

Sansone (1980) published the first retention study of the TC using the

“life table” technique, whereby survival in treatment is depicted over

points in time after admission. Sansone studied Odyssey House clients;

although the study did not focus on adolescents, the population was

divided into age ranges, permitting the independent analysis of retention

for a youth group.

The Odyssey House sample included admissions during the early 1970s

(table 2, fifth column). Sansone’s report distinguished three age groups,

but no group was equivalent to the age range of 19 and younger

established by the DARP study. Clients 21 and under were chosen to be

the youth group of interest for this review (sample size = 332). The

population at Odyssey House at that time was mixed for adults and youth.

The data presentation did not permit a determination of demographics

and referral circumstances independently for the youth group, and there

was no description of pretreatment drug use.

Retention

The median TIP of approximately 82 days and first-month dropout rate of

approximately 32 percent (table 3, fifth column) were reasonably close to

the respective figures for DARP and TOPS. The completion percentage

was unavailable in the report. The youth were not retained in treatment

as well as the adults, who had a median TIP of 105 days; this last result is

discrepant from DARP and TOPS.

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Summary

The Odyssey House study replicated the adolescent retention

indicators of DARP and TOPS.

Retention for adults was appreciably better than for youth, which did

not replicate DARP and TOPS.

PHOENIX HOUSE

De Leon has assembled the definitive data set for an individual TC,

specifically, Phoenix House. This effort was funded by NIDA. In a

paper that was secondary (De Leon 1984a) to the main presentation of

Phoenix House outcome data (De Leon 1984b), findings on the

relationship between age and outcome were reported. The treatment time

period studied was 1974 (table 2, sixth column). The youngest age group

was defined as 18 years of age and younger. The youth in this age range

were 21 percent of the total Phoenix House population, and they were

treated in the same milieu as the adults. The number of youth

contributing to the analysis was low (sample size = 84).

Demographics and pretreatment drug use for the youth group were made

available (Jainchill, personal communication, 1991). As seen in the table,

there was a much lower proportion of whites in the youth group than in

DARP, the Pennsylvania study, and TOPS. The use of opioids was not

as high as that reported for DARP, but it was higher than that reported for

the Pennsylvania study and TOPS. This may reflect the treatment era

studied, which falls between that of DARP and the other two studies.

Note that, in parallel with the Pennsylvania study and TOPS, nearly half

of the Phoenix House youth were referred by the justice system.

Retention

The only retention indicator that could be derived from the report was the

completion percentage (table 3, sixth column). A total of 17 percent of

the youth group completed treatment, which was higher than the

completion percentage of 11 percent for the adult clients.

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Outcome

Table 4 (last column) shows that the followup interval for the Phoenix

House study was 2 years after discharge, and the pretreatment and

posttreatment assessment time periods differed at 1 year and 2 years,

respectively. De Leon applied a “success index” to the age groups, which

was a four-point scale that integrated drug and criminal indicators.

Employment was excluded from the scale, as it was highly correlated

with the drug and criminal indices and added no new information.

The success index showed a pretreatment to posttreatment improvement

for adolescent clients that did not differ significantly from that of older

clients. However, the author noted that adolescent dropouts with justice

system involvement had the poorest outcomes. There was a correlation

between outcome and TIP for adolescent completers and dropouts

combined; this correlation, however, was not found for adolescent

dropouts alone (De Leon, personal communication, 1991).

Summary

For Phoenix House, youth showed higher retention in treatment than

adults.

The youth showed overall improvement in treatment, but legally

referred dropouts continued “to use drugs and commit crime

regardless of their . . . length of stay in treatment” (De Leon

1984a, p. 26).

Nevertheless, the overall conclusion of the Phoenix House study

was that “adolescent outcomes are not unlike those of adults”

(De Leon 1984a, p. 28).

A TIP effect was found for the Phoenix House youth group overall,

but not for dropouts alone.

TCA CONSORTIUM

De Leon (1980) also directed a NIDA-sponsored project to develop

research capability in seven TCA member programs (see also De Leon

and Schwartz 1984). The project report presented retention data,

including that for a youth group, for the consortium of seven TCs. The

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treatment time period studied was 1979 (table 2, seventh column). As

with the Gateway Houses and Phoenix House data sets, the youth group

was defined as 18 years of age and younger. This group comprised 21

percent (sample size = 229) of the total TC population and was treated

together with adults. Gender data were available for the youth group

(Jainchill, personal communication, 1991).

Retention

For the combined youth groups of the seven TCs, the median TIP was

about 60 days, and the percentage who dropped out during the first

month was about 37 percent (table 3, seventh column). The 60-day

median TIP was lower than all but one reported in this review, and the

first-month dropout rate was the highest reported.

Although the TCA youth exhibited relatively low retention in treatment,

youth retention was still better than that of the total population, which

exhibited a median TIP of 45 days. In fact, the retention difference

between youth and adults was even more extreme, as the total population

data included the adolescents.

Summary

Retention in treatment for the TCA consortium adolescents was low

relative to the field.

Nevertheless, adolescents had higher retention rates than adults.

ABRAXAS FOUNDATION

The Abraxas Foundation has contributed its report (Pompi and Resnick

1987) to the series of retention studies that have depicted survival in

treatment over points in time after admission. The treatment era spanned

by the study was exceptionally long, more than 10 years (table 2, eighth

column). One comparison in the report divided the population into

legally juvenile and adult groups; the juvenile group was approximately

18 years of age and younger and comprised 69 percent of the total

population. (The Abraxas Foundation has since become 100-percent

juvenile.) The number of clients in the juvenile group was very robust,

over 1,000, and the drug usage of this group was known to be primarily

polydrug and nonopioid. In contrast to preceding studies reporting

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referral sources, the Abraxas Foundation’s population was almost totally

referred by the justice system.

Retention

The juvenile group exhibited dramatically high retention relative to that

of the other reported studies for two of three indicators (table 3, eighth

column). The juveniles spent 18 1 median days in treatment, and only 13

percent left within the first month; however, only 18 percent of them

completed treatment.

The retention rates for the adults were even better. The median TIP for

the adults was well beyond the 300-day cutoff for the study, and 42

percent of the adults completed treatment. The argument was made in the

study that court pressure was responsible for the high retention of

Abraxas Foundation clients relative to other TCs and, furthermore, that:

. . . court-referred adults may remain in treatment longer than

court-referred juveniles because they feel more pressure to

complete treatment from the criminal justice system than

juveniles do from the juvenile justice system (Pompi and Resnick

1987, p. 322).3

Another factor in the program’s high retention may be that it is located in

a rural area; therefore, the clients have limited access to public

transportation to abscond (Jainchill, personal communication, 1993). The

longer median TIP for adults found in the Abraxas Foundation study

parallels that of only one other study in this review, Odyssey House.

Summary

The almost totally court-referred Abraxas Foundation juveniles

exhibited dramatically high retention relative to the field on two of

three indicators.

Retention for adults was dramatically higher than retention for youth.

TWO NEW YORK TCs

The final data set to be discussed is from a recently completed study of

adolescents admitted to two New York City TCs (De Leon and Jainchill

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1992). As shown in table 2 (ninth column), one of the TCs, TC 1, is the

only program in this review that treated adolescents exclusively. For TC

1, the age range for the population was 18 and younger; for TC 2, the age

range for the youth group was defined as 19 to 21.

The number of youth in each TC available for analysis was small (sample

sizes = 70 and 68). The TCs differed dramatically in the percentage of

whites in the population. Both TCs differed from preceding data sets in

that the majority of clients were involved primarily with cocaine and

“crack,” reflecting the prevalence of those drugs during the time period of

the study. TC 1 had over half of its population referred by the justice

system.

Retention

The only retention statistic available was the first-month dropout rate,

which was 27 percent and 18 percent for TC 1 and TC 2, respectively

(table 3, ninth column). These statistics fall within the range established

by previous data sets.

Summary

Youth recently admitted to two New York TCs were heavily

involved with cocaine and crack.

Dropout rates for the youth were not exceptional.

TWO MORE STUDIES

Before proceeding to the conclusions of this review, two other studies are

considered. The first is distinguished by virtue of its being the first

published study that focused exclusively on adolescents in a TC. Biase

(1971) found that the depression score of the Multiple Affect Adjective

Check List (MAACL) predicted which adolescents (mean age = 16) at

Phoenix House dropped out of treatment during the 6 months after

testing. The dropouts had registered significantly higher MAACL

depression scores than those who remained in treatment. In contrast, no

significant differences were found between the two groups on MAACL

anxiety or hostility scores.

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The second study was recent and represents a rarity—a process study that

focused on a treatment factor thought to be essential to the successful

retention and treatment of adolescents. Weidman (1987) capitalized on

what he called a “naturally occurring experiment” to explore the effects of

family therapy and staff training on the retention of TC adolescents. In

the nomenclature of Campbell and Stanley (1966), the study

approximated a “nonequivalent control group” design whereby an

experimental group is given an intervention while a control group is not.

Both groups are given pretreatment and posttreatment testing, and the two

groups are “naturally assembled collectives.” One of the facilities of a

suburban District of Columbia TC changed its treatment philosophy to

include structural family therapy (Minuchin and Fishman 1981), while

another facility did not. Both facilities were said to be otherwise identical

in treatment approach and philosophy. Weidman looked retrospectively

at adolescent retention for both facilities for a time period of 9 months

before the introduction of structural family therapy to the experimental

facility and for a time period of 9 months after that point.

The new family therapy approach involved” . . .viewing the facility as a

large family, using structural concepts in group work, and having the

family therapists use the structural approach in their work with families”

(Weidman 1987, p. 24).4 Furthermore, the staff of the experimental

facility were involved in a weekly training program in structural family

therapy.

A total of 43 adolescents at the experimental facility and 49 adolescents

at the control facility were followed; the subjects ranged from 14 to 20

years of age. The primary finding was that, as expected, the number of

adolescent dropouts showed a significant decrease during the 9 months

following the introduction of family therapy at the experimental facility,

but not at the control facility. Bolstering this initial finding was the

secondary finding that in the experimental facility, families of the

dropouts attended family therapy at a significantly lower rate than

families of the clients who remained in treatment. These data support the

hypothesis that family involvement in the treatment of adolescents is a

potent factor in their retention in the TC.

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CONCLUSIONS

Retention

Of the nine studies presented in this review, the retention statistic of

median TIP was available for six studies and ranged between 35 and 181

days for TC adolescents; the four middle scores were clustered between 2

to just over 3 months. Seven studies permitted the comparison of youth

with adults in median TIP, completion rate, or both; of these:

Two showed an appreciable retention advantage for youth.

Three showed little retention difference between youth and adults.

Two showed an appreciable retention advantage for adults.

Thus, the results of the comparisons vary. However, only two studies

showed an appreciable disadvantage for youth. One of these was the

Abraxas Foundation study (Pompi and Resnick 1987), where median TIP

for youth at 181 days was by far the highest reported in this review, albeit

lower than that for adults.

The first question posed at the beginning of this review was: Are

adolescents retained in TC treatment? The results presented above lead to

this answer: Adolescents generally are retained in TCs about as well as

adults. It appears that conclusions drawn about the ability of TCs to

retain the general population of clients also apply to the special

population of adolescents. However, there are inconsistencies in the data,

and more work needs to be done.

Outcome

Of the nine studies reviewed, four reported on posttreatment outcomes.

Of these four, three presented outcome data on substance use. All three

studies showed an overall decrease in substance use by adolescents after

TC treatment in comparison with pretreatment use, with this exception:

One study showed a slight increase in marijuana use and little change in

alcohol use.

Two of the four studies reported employment as an outcome indicator;

both showed an increase in employment after treatment. All of the four

studies reported indicators of criminality; all four showed a decrease in

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criminal involvement after treatment. Of the four outcome studies, three

permitted a comparison of youth with adults. Two of these studies

showed no difference between youth and adult outcomes, but one study

showed an advantage for adults.

Two of the studies permitted a comparison of TC and outpatient drug-free

modalities in regard to youth outcomes; both showed an advantage for

TCs.

Finally, all four of the outcome studies showed a positive relationship

between outcomes and TIP (that is, a TIP effect for TC-treated

adolescents). In the absence of an experimentally defined control group,

the presence of such a relationship strengthens the inference that TC

treatment caused the positive changes in the youth sample and reduces

the credibility of alternative explanations for the changes, such as

“regression” or “maturation.”

The second question posed at the beginning of this review was: Do TCs

produce successful outcomes with adolescents; that is, do they reduce

substance use and crime and increase productive behavior? The evidence

leads to this answer: The conclusions drawn from outcome studies of

TCs in general (that TCs are effective in reducing drug use and crime and

increasing productive behavior) appear to apply to the special population

of adolescents. However, data on adolescents remain scarce.

DISCUSSION

The issue of posttreatment marijuana and underage alcohol use remains

problematic. DARP did not show a positive impact by TCs on the

adolescent use of marijuana and alcohol; although TOPS did show

decreases for both substances by adolescents, the impact was

disappointing. It appears that earlier TCs did not focus on adolescents’

use of alcohol and marijuana. Is total abstinence from all substances the

treatment goal for TCs working with adolescents today? Do

“recreational” marijuana use and underage drinking predispose

adolescents to relapse in other drug classes?

As seen in this review, adolescents tend to be referred in significant

numbers by the justice system. Court pressure, therefore, is an important

variable that demands further investigation. The Abraxas Foundation

study (Pompi and Resnick 1987) attributed its finding of high retention to

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the impact of court pressure. An early paper by Lissner and colleagues

(1976) declared that for TCs accepting court-referred clients, the clinical

program must work with the judges and probation officers and develop a

partnership to keep the clients in treatment. Therefore, the relationship

between the program and the court is key. Furthermore, so-called

voluntary clients enter treatment under external pressure—from family,

friends, schools, and others interested in their welfare. Court pressure

may be one of a spectrum of external motivators to bring clients into

treatment (Heit and Pompi 1977), albeit the one that may be most

evident. These factors have yet to be clarified for adolescent clients.

It has been the author’s experience with the Abraxas Foundation

population that most court-referred adolescents are oppositional, in denial

of their problems, and not motivated for treatment at admission. Many of

these clients appear to become motivated, looking more like voluntary

clients, as a result of their initial months in the TC milieu. This withintreatment phenomenon needs to be explored.

The importance of court pressure may apply to treatment outcomes as

well as to treatment retention; this issue is in need of data. If court

pressure lengthens the stay of adolescents in TC treatment by reducing

dropout, do the clients thereby profit more from treatment? Alternatively,

do they just mark time, not buying into the treatment process, until the

court stipulation runs its course?

Delinquency and conduct disorder also must be addressed in adolescents.

For instance, the Abraxas Foundation is receiving an increasing number

of referrals whose primary presenting problem is delinquency,

particularly drug selling, with little concomitant drug use. Do these

clients belong in the TC?

There are data indicating that psychological factors play a role in the

treatment retention of juveniles. For instance, Biase (1971) showed that

depression scores predict eventual dropout. It is thought that adolescents

may be more generally distressed than adults entering TCs. The TOPS

authors stated:

Most youth entering drug treatment programs have a complex

array of drug abuse, alcohol use, delinquency, and mental health

problems. . . . In addition to substance abuse and problems

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attributed directly to youth, about one-half the youth report suicidal

thoughts or attempts in the year prior to entering treatment (Hubbard

et al. 1985, p. 64).

Therefore, flags for mental health problems that may result in early

dropout, such as the MAACL, need to be further elucidated.

Education and vocational preparation are critical for adolescents in

general; this appears even more true for adolescents in TCs. The

influence of education and job success on posttreatment relapse in

adolescents should be researched.

Weidman’s study (1987) demonstrated that involving the families of

adolescents in therapy positively impacts treatment retention. This

interesting and reasonably well-controlled study should be followed up

with more such studies of the role of the family in treatment and in

reentry, aftercare, and relapse prevention.

The question of mixing adults and adolescents in the TC treatment milieu

is an issue that has not only clinical significance but economic and

political significance. There are obvious advantages to treating both

groups in the same facility. It is more expensive to segregate than to

integrate special populations from an economy and bed utilization

perspective. Adolescent clients do not perform as surrogate staff as well

as older clients, and mixing assists the economy of staffing for the

adolescent group. There also are disadvantages. For example, the older

clients may “turn on” and “turn out” the younger clients in regard to

heavier drug use and more serious criminal activity. The general public

and licensing agencies also may frown on such mixing. In facilities that

also mix the sexes, these concerns may be even more acute. The question

of treatment segregation versus integration of adolescent clients has not

been addressed in TC-based studies.

How have traditional TC programs and practices changed to meet the

needs of adolescents (and the requirements of their funding sources and

licensing agencies)? Has the atmosphere of confrontation been softened?

Are adolescent clients used as staff surrogates? Is group therapy being

deemphasized in favor of more individual therapy? Have program

components, accountability, paperwork, external reporting requirements,

general overhead, and thus the expense of treatment increased? Do

licensing agencies with their regulations, such as the proscribing of

menial labor, dilute the TC milieu for adolescents? Is planned duration of

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stay in the TC different for adolescents and adults; if so, is this a clinical

or a funding consideration? Can adolescent programs mix the sexes as

comfortably as adult programs? Are there data to track these issues and

to justify whatever changes have been made in TC practices over the

years to accommodate the adolescent client?

Deitch and Zweben (1976) discussed such issues in a clinical paper that

provided early and prescient recommendations for making “contemporary

treatment more responsive to the needs of adolescents.” De Leon and

Deitch (1985) provided further discussion of the adolescent in the TC.

Beschner and Friedman (1985) reviewed the correlates and associated

problems of adolescent drug abusers and their various treatment settings.

A NIDA research monograph edited by Rahdert and Grabowski (1988)

critically reviewed adolescent assessment and treatment process; these

assembled reports can be read with the TC milieu in mind. Owen and

Winters (199 1) provided an updated review of adolescent treatment

outcome studies and significant treatment issues with recommendations

for future research.

RESEARCH RECOMMENDATIONS

Two major studies on adolescents are being funded by NIDA in the

1990s. The Drug Abuse Treatment Outcome Study (DATOS), which

includes the study of adolescents as well as adults, is the third in a series

of large-scale multimodality outcome studies following DARP and

TOPS. The other study involves the evaluation of adolescents admitted

to six TCs (Jainchill and Bhattacharya, in press). These two studies

should eventually answer critical questions about the current retention

and posttreatment outcome of adolescents in TCs. These major studies

may preempt the funding of followup studies for individual programs,

particularly if they are based on quasi-experimental research designs.

Hence, it may be politic for TC-based researchers to focus on the

following:

Outcome studies that are true experiments; the uniqueness and power

of this approach should attract funding.

Process studies that explore the elements of treatment, including

those that enhance retention; as such studies are few, a broad range of

methodologies should attract funding.

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In regard to treatment outcomes, researchers in the past have looked for a

correlation between posttreatment success and TIP as evidence of

treatment impact. The following issues are notable in trying to use this

strategy for court-referred adolescent clients:

The juvenile courts increasingly are stipulating a maximum duration

of stay for drug treatment. Due to funding constraints, the maximum

time is getting shorter. Whatever the achievements of the client

during the stipulated time period, he or she is to be discharged by the

program at the period’s conclusion. This may result in an insufficient

range of treatment durations for a robust correlation between TIP and

outcome to appear.

The courts may stipulate the more dysfunctional and recalcitrant

client to a longer duration of stay than usual, which works against the

TIP effect.

As discussed in the section on Abraxas Foundation client retention,

court pressure may reduce dropout significantly; hence, courtreferred clients may not show the self-selection artifact that

contributes to the TIP effect as much as clients who are not in the

justice system.

Therefore, for court-referred clients, it may be difficult to tease out a true

dose-response relationship in a TIP analysis and impossible to compare

the result with that found for voluntary clients. A stronger study design is

needed to support the conclusion that TC treatment causes the

posttreatment improvement in this population. Would the juvenile courts

accept an experiment with random assignment to TC treatment versus a

nontreatment alternative or, if that proves too uncomfortable, to shortterm versus long-term TC treatment? One advantage of using stipulated

clients is that court pressure reduces the tendency for attrition in the

group assignments.

In regard to treatment process, an important initial step would be to

determine the current state of affairs in the treatment of adolescents in

TCs. Another survey of the membership of TCA should be undertaken,

and questions pertaining to adolescents should be included. These

programs would be asked what they are doing in regard to this special

population and why they are doing it. Some obvious areas of inquiry are:

155
Referral circumstances;

Relationship of the program to referral sources, particularly the

courts;

Problem domains presented by adolescents (e.g., mental health

co-morbidities, delinquency, dysfunctional family systems, and

school difficulties);

Cocaine and crack involvement;

Initial motivation and problem denial;

Planned duration of stay;

Treatment retention;

Program philosophy toward marijuana and alcohol use;

Mixing versus segregation of adolescents and adults;

Mixing versus segregation of the sexes;

TC procedures and tools for adolescents;

Softening of the atmosphere of confrontation;

Use of adolescents as staff surrogates;

Use of adolescents for menial labor;

Individual versus group therapy;

School and vocational programs;

Family involvement and therapy;

AIDS prevention;

Treating delinquency as well as drug abuse;

Programs for drug sellers;

156
Reentry, aftercare, and relapse prevention strategies;

Juvenile licensing, oversight, and funding agencies and their

influence; and

Accountability, paperwork, external reporting, general program

overhead, and cost.

The answers to these issues would provide a grassroots framework for

developing research questions of import for treatment process analyses.

Several such treatment process questions have been adduced in this

chapter. One that particularly appeals to the author is the hypothesized

“flip” shown by oppositional youth when they appear to accept treatment.

Many court-referred youth—who begin their stay absolutely opposed to

treatment, not believing that they have a problem, and complaining that

they have gotten a bad deal from the judge—appear to change for the

better early on in the TC milieu. It would be interesting to try to track

this phenomenon. Is it a real change in attitude? Can it be predicted at

admission? Can the probability of it happening be enhanced? Does it

predict treatment retention and posttreatment outcome? A withintreatment study could explore these questions for oppositional

adolescents, perhaps using the Circumstance, Motivation, Readiness, and

Suitability (CMRS) instrument developed by De Leon and Jainchill

(1986).

Finally, researchers should be vigilant to capitalize on program changes

and improvements that can be researched; perhaps there are other natural

experiments like that of Weidman’s study (1987). TC administrators

might be encouraged (with administrative support dollars from research

grants) to phase in new program elements with part of the program

population so that a quasi-experiment, at least, is possible. An era of

TC-based process studies thus could begin for adolescents. If a process

study is successful, it lends indirect credibility to the hypothesis that TCs

cause their positive posttreatment outcomes; a series of successful

process studies investigating a variety of hypotheses would powerfully

make this point.

NOTES

1. Reprinted from Pompi and Resnick (1987, p. 311) by courtesy of

Marcel Dekker, Inc.

157
2.

3.

4.

Reprinted from YOUTH DRUG ABUSE, George M. Beschner and

Alfred S. Friedman, eds. Copyright 1979 by Lexington Books, an

Imprint of Macmillan, Inc. Reprinted by permission of the publisher.

Reprinted from Pompi and Resnick (1987, p. 322) by courtesy of

Marcel Dekker, Inc.

Reprinted with permission from Journal of Substunce Abuse

Treatment, Vol. 4, Weidman, A. Family therapy and reductions in

treatment dropout in a residential therapeutic community for

chemically dependent adolescents. Copyright 1987, Pergamon Press.

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18:203-208, 1986.

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Drug Abusers: Evaluation of Effectiveness.” Final report of project

activities under National Institute on Drug Abuse grant no.

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retention rates? Am J Drug Alcohol Abuse 10:267-284, 1984.

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residential treatment. Addict Ther 2:1-3, 1977.

Holland, S. Gateway Houses: Effectiveness of treatment on criminal

behavior. Int J Addict 13:369-381, 1978.

Holland, S. Adolescent and adult drug treatment clients: Patterns and

consequences of use. J Psychoactive Drugs 16:79-89, 1984.

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Adolescent Substance Abusers. National Institute on Drug Abuse

Research Monograph. DHHS Pub. No. (ADM)85-1342. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1985. pp. 49-65.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh,

E.R.; and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina, 1989.

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Proceedings of the 15th World Conference of Therapeutic

Communities, in press.

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coordinating treatment with criminal justice. Am J Drug Alcohol

Abuse 3:621-628, 1976.

Minuchin, S., and Fishman, H.C. Family Therapy Techniques.

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Prentice Hall, 1984.

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outcome research. In: Spicer, J., ed. Does Your Program Measure Up:

An Addiction Professional’s Guide for Evaluating Treatment

Effectiveness. Center City, MN: Hazelden Foundation, 1991. pp. 135-

153.

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13:309-325, 1987.

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of Treatment Research. National Institute on Drug Abuse Research

Monograph 77. DHHS Pub. No. (ADM)88-1523. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1988.

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clients in the Pennsylvania substance-abuse system. In: Beschner,

G.M., and Friedman, A.S., eds. Youth Drug Abuse. Lexington, MA:

Lexington Books, 1979. pp. 629-656.

Sansone, J. Retention patterns in a therapeutic community for the

treatment of drug abuse. Int J Addict 15:711-736, 1980.

Schiamberg, L.B. Human Development. New York: Macmillan, 1985.

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adolescents. J Subst Abuse Treat 4:21-28, 1987.

ACKNOWLEDGMENT

David H. Kerr, Integrity, Inc., Newark, NJ, is acknowledged for

providing the TCA survey data for table 1.

160
AUTHOR

Kenneth F. Pompi, Ph.D.

Vice President

Research and Information Management

The Abraxas Group, Inc.

Two PNC Plaza

Suite 2300

Pittsburgh, PA 15222

161
Therapeutic Communities:

Substance Abuse Treatment for

Women

Sally J. Stevens and Peggy J. Glider

INTRODUCTION

Therapeutic communities (TCs) have established themselves as a

treatment modality for many special populations of substance abusers.

The foundations or roots of the TC were based in the tradition of the

Alcoholics Anonymous 12-step method and first applied to the treatment

of male heroin addicts (Rom-Rymer 1981). As the TC movement grew,

the methodologies used and services provided were expanded and

adapted to meet the special needs of a number of typically underserved

populations. Of the groups receiving treatment within the TC, those most

often studied included those with criminal justice involvement and those

with co-morbidity issues. Other special populations that have received

less attention are adolescents, ethnic minorities, the homeless, and

women. The focus of this chapter is the special population of women in

substance abuse treatment, primarily in TCs.

Specialized programs for women within TCs have been available for over

two decades, but women remain an underserved population. Prior to

1970, there were very few attempts made to understand substance abuse

among women. The National Institute on Drug Abuse (NIDA) addressed

the problem of underservice to women in 1974 by establishing a program

for women’s concerns. In 1976, a national conference on women’s issues

was held that focused on identification of treatment needs of women and

types of programs that would have a positive impact on the female drug

abuser. Public Law 94-371 was passed in 1976, granting priority

considerations for the funding of women’s treatment and prevention

services (Beschner and Thompson 1981). In 1979, a survey was

conducted to identify all the substance abuse agencies in the United

States that provided specialized treatment services to women; only

44 programs were identified (Beschner and Thompson 1981).

162
During the middle to late 1980s, an increased interest in substance abuse

services for women was beginning to emerge. This interest was the result

of several factors. First, the number of women seeking treatment was

increasing drastically in many communities. For example, Palley (1991)

cited the following statistics: “Only 12 female cocaine users sought

treatment in Philadelphia 10 years ago. In 1989, there were more than

3,300. Today, nearly half of the addicts in the city are women . . .”

Similar increases are reported for New York City, where the number of

women using cocaine during pregnancy has more than quadrupled

between 1985 and 1990 (Sofer, unpublished data).

Second, the Omnibus Drug Bill was passed in 1986, increasing funds

available for substance abuse research and demonstration programs. One

outcome of this was the development of the Office for Substance Abuse

Prevention, whose primary focus was high-risk youth. One key risk

factor identified was being the child of a substance abuser. This focus

increased the interest in substance-abusing women, as they were most

often the primary caregiver and the single parent responsible for these

children.

In addition, the impact of perinatal substance use on the fetus and future

development of the child became a growing concern. Data from 1989

reported by the Los Angeles County Department of Children’s Services

in Edelstein and colleagues (1990) indicated that referrals for drugexposed infants increased 500 percent from 198 1 to 1987. The New York

Times quoted Elizabeth Graham, New York City’s assistant health

commissioner, saying that cocaine abuse among pregnant women had

increased 3,000 percent over the last 10 years (Rist 1990). The National

Association for Perinatal Addiction Research and Education reported that

in a national survey of hospitals, over 16 percent of all newborns tested

positive for cocaine in their urine. A 1989 survey conducted by the

Select Committee on Children, Youth, and Families found that 15 of the

18 hospitals surveyed had experienced a three- to four-fold increase in

drug-exposed births since 1985 (Kronstadt 1991). Similarly, in

Philadelphia, 20 percent of all babies born during 1990 had cocaine in

their systems (Palley 1991).

As a result of the increasing prevalence of the problem and legislative

interest, services to women have increased. However, although women

comprise approximately one-third of all addicts nationally, women are

eligible for only one-fifth of the available treatment slots calculated

across all types of treatment modalities (Palley 1991). Also, little

163
empirical research from programs for women has been published. This

lack of published research makes it difficult to derive an accurate picture

of female drug abuse patterns.

Treatment statistics, often unpublished, are a primary source for

identifying drug use patterns; however, this source of information has its

limitations. Few standardized instruments or data collection procedures

are used across multiple programs, making cross-site comparisons

difficult. Only a few national studies have been conducted that attempt to

collect, compile, and analyze this immense database (e.g., Drug Abuse

Reporting Program, Treatment Outcome Prospective Study, Drug Use

Forecasting). In addition, treatment statistics only describe those

individuals who actually enter treatment, a very small portion of the total

number of substance abusers. Regardless of these methodological

limitations, a wealth of valuable information is available that describes

the characteristics of treatment participants at intake and posttreatment

outcomes.

This chapter discusses what is known about substance-abusing women

who have enrolled in a TC for substance abuse treatment and provides

suggestions for future treatment and research efforts. The topics covered

include a profile of women in treatment in terms of demographics and

legal, medical, social, economic, and psychological needs.

NATIONAL PROFILE OF WOMEN IN TCs

Demographics

Of the 56 million American women of childbearing age (ages 15 to 44),

approximately 15 percent currently are substance abusers (Moyers 1989).

Only a small percentage of these women enter any kind of substance

abuse treatment. A profile of those women entering TCs follows.

Ethnicity varies widely depending on the geographic location of the TC

program. For example, Caton House in Philadelphia reports that 96

percent of their women are African American (Walsh et al. 1991);

Operation PAR in Florida is 90 percent African American,

5 percent Hispanic, and 5 percent white (Hughes et al. 1991). At Amity,

Inc., in Tucson, AZ, 61 percent are white, 21 percent are Hispanic, 13

percent are African American, 4 percent are Native American, and

1 percent are Asian American (Glider, unpublished data). The age of

164
women upon entry into a TC for treatment also varies by program.

However, most programs provide services to women ages 18 to 35, with

the mean age of 27 years (Stevens 1988).

The educational level of women entering TC treatment generally shows a

trend for few high school graduates. For example, Caton House (Walsh

et al. 1991) reported that more than 60 percent of its clients dropped out

of school, 26 percent completed high school or have a General

Equivalency Diploma (GED), and 13 percent attended or graduated from

college. Similar statistics were reported for Operation PAR (Hughes et

al. 1991), with only 10 percent of its clients completing high school or

getting a GED and an additional 15 percent completing some post-highschool education.

Legal Issues

Since 1980, the number of women incarcerated has increased 134 percent

(Moss 1990), and many of these women are addicts. Often, these women

trade sex for drugs or money in their effort to support their drug habit.

When women are arrested, they are sentenced to jail or prison for illegal

sexual behavior rather than for a drug-related offense; thus, they are not

stipulated into drug treatment by the legal system (Silbert et al. 1982).

Thirteen percent of women in any type of treatment have been stipulated

by the legal system to treatment; however, 39 percent of women reported

being arrested within the 2-year period prior to entering treatment

(National Institute on Drug Abuse 1979). This discrepancy provides

evidence of the legal system’s reluctance to intervene in women’s drug

habits either by jail or treatment (Beschner and Thompson 1981).

Evidence for the legal system’s reluctance to stipulate women to

treatment is supported by data from TCs. For example, at Amity, years

of addiction before being stipulated to treatment ranged from 5.8 years

for African-American women without children to 14.1 years for Hispanic

women with children. Moreover, courts delay intervention because

women have children (Arbiter, unpublished data). Across ethnic groups,

women without children are arrested and placed in jail after a shorter drug

experience than women with children (table 1).

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TABLE 1. Women in the Amity/Pima County jail project, 1987-1989

(n = 90)

Characteristics n

Number who are mothers

Total number of children from the 67 mothers

Average years of addiction

White women without children

White women with children

Hispanic women without children

Hispanic women with children

African-American women without children

African-American women with children

Number who went on to long-term treatment

Total number rearrested

Of those rearrested, number who went to prison

67

164

7.1

12.5

8.7

14.1

5.8

8.2

33

21

8

Medical Issues

Beschner and Thompson (1981) reviewed the literature on the health

problems of female substance abusers. The review reveals that women

are more likely than men to cite physical problems as the motivating

factor for entering treatment. Women suffer from a variety of problems,

including infection, anemia, venereal disease, toxemia, hepatitis,

hypertension, and diabetes. Some of these problems arise from an

unhealthy lifestyle—one with little concern for hygiene, health, or

nutrition. These women also are at greater risk for gynecological

problems, including malignancies, and have a number of unplanned

pregnancies. Due to the increase in crack-cocaine smoking among

women, their general health is even more debilitated with an increased

incidence of respiratory problems. To get drugs, women often

prostitute—putting themselves at risk for sexually transmitted diseases

(STDs) (Stevens et al. 1993).

Medical problems are common among women who enter TCs (Stevens,

unpublished data). In part, this may be due to the lack of ongoing

166
preventive health care. Stevens and colleagues (1989) report that many

women fail to have Pap smears on a regular basis and, in fact, display

ignorance about even basic facts regarding their bodies and reproductive

functions. Furthermore, their neglect of nutrition and prenatal care

compromises their pregnancies.

At Amity, women report numerous health problems at intake. The most

commonly reported health problems include STDs such as chlamydia and

gonorrhea, complications from lack of prenatal and postnatal care,

complications from lack of care following abortions and other traumas to

the female reproductive system, and respiratory system and dental

problems. Given that 41 of the 55 women in Amity’s long-term

residential TC admitted to histories of prostitution, with the average

number of years of prostitution equaling 5, it is not surprising that

medical problems specific to the female anatomy are commonplace

(table 2).

TABLE 2. Survey of 25 TCA membership agencies

TC Characteristics Number

Number of people being served in all components

Number of States represented

Number of agencies whose populations are more than

50% minority

Average breakdown between men and women

Agencies that reported that most people they served

were parents

Agencies that did not know who were parents or who

treated adolescents

Agencies that had a program for mothers and children

Agencies that had provisions for fathers and children

Agencies that have a waiting list to enter

Average time a person must wait to enter treatment (months)

11,634

10

10

70%:30%

17

8

10

0

23

4

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Social and Economic Issues

In 1986, 16 percent of the Nation’s families were headed by women,

while 51 percent of the families living in poverty were headed by women

(Abramovitz 1988). The social and economic conditions of the women

who enter public-supported drug treatment programs are very poor.

Exacerbating their poverty, most of these women have children.

Beschner and Thompson (1981), in a NIDA monograph on women and

drug abuse treatment, reported that 73 percent of the women in the

Washington, DC, program were mothers, but they noted that few drug

treatment programs provided childcare services.

These women typically come from fragmented family structures that

decrease the social support they can call on for childcare while they are in

treatment. Even if a family exists to provide childcare while the mother

is in treatment, that family may be dangerous for the child, replicating the

same environment from which the drug-addicted woman came.

Women who enter TCs for substance abuse treatment typically are from

lower social and economic backgrounds and from metropolitan areas that

evidence poverty and fragmented families. Gaudenzia, Inc. (unpublished

data) in Philadelphia reported that most women who enter treatment

receive welfare. Over 90 percent of the women who enter Amity

experienced poverty, violence, drug use, and crime in or around the home

where they grew up. Many of these women now have children, and they

have few choices of where to place their children while they are in

treatment. Not willing or not able to leave their children with family

members with whom they grew up, these women often are expected by

court and childcare agency officials to put their children in foster care or

even have parental rights severed in order to enter treatment (Stevens et

al. 1989).

In addition, women who entered the Amity long-term residential TC

indicated that they did not seek treatment due to social pressures placed

upon them. They often feel that they suffer more severe social sanctions

than men if they admit abusing drugs. Women are not expected to use

drugs to the extent that it interferes with their ability to care for their

children. Since women are seen as the primary childcare providers, they

are expected to be home with their children rather than in treatment for

themselves and their own drug addiction (Stevens et al. 1989).

168
Psychological Issues

Women and men show similar psychological problems and needs;

however, women’s problems often are more severe. Whenever one looks

at a woman in treatment, “Generally she is much sicker and harder to

treat. Her relationships with men have been terrible. She has been used,

sold, beaten, violated, conquered, derided and exploited” (Densen-Gerber

et al. 1972). A significant percentage, as high as 60 percent of women

who enter treatment, report that they have experienced incest and

molestation as children (Densen-Gerber and Rohrs 1973). Additionally, a

1980 NIDA study showed that 70 percent of addicted women had been

raped or molested prior to their substance abuse (Wasnick et al. 1980).

Women who enter TCs also evidence a high percentage of incest and

molestation as children and frequently experience rape as an adult. At

Amity, of the 55 women who were enrolled in the long-term residential

TC in 1991, 35 had been raped or molested before the age of 21, and an

additional 15 had been raped after the age of 21 (table 3).

De Leon (1989) reported that women entering TC treatment display more

severe psychopathology than men entering the same programs. (This

finding is discussed in another chapter in this monograph.) Of interest,

however, is De Leon’s finding, after a review of the literature, that

women show greater improvement during and following treatment in a

TC than males (De Leon 1989).

In terms of self-concept, both clinical and research studies confirm that

poor self-concept is a feature of substance abusers, as measured by the

Tennessee Self Concept Scale (De Leon 1988). Typical profiles for both

men and women show deviance in both of the self-esteem and adjustment

scales. Women’s profiles, however, evidence consistently poorer scores

on measures and symptoms of self-esteem at admission (De Leon 1989).

CURRENT TC SERVICES FOR WOMEN: A NATIONAL

PROFILE

In the late 1980s and early 1990s an increasing number of women’s

programs began emerging within TCs nationally. In May 1990, Amity

conducted a survey of 25 of the largest and oldest member agencies in

Therapeutic Communities of America (TCA), which is an association of

169
TABLE 3. Amity long-term residential TC: Characteristics of women in

treatment in 1991 (n = 55)

Characteristics n

Average age 27

Age range 14-53

Combined number of children 70

Drug History

Intravenous drug users

Average number of years using drugs

Number for whom Amity was first treatment alternative

Number who attempted other treatments prior to Amity

Average number of treatment attempts

Sexual History

Histories of prostitution or trading sex for drugs

Average number of years of prostitution

Average (low) estimate number of sexual partners over

the 2-year period prior to entering treatment

Percent (of 41) who never used a condom

Percent (of 41) who seldom used a condom

Number of women raped or molested before age 2 1

Average number of rapes

Number of women raped after age 21

Average number of rapes

Arrests

No arrests

Arrested between 1-5 times

Arrested between 6-10 times

Arrested over 11 times

Average age at first arrest

Number on probation, intensive probation, or parole

Percent who used drugs in jail or prison

Average number of years incarcerated as a juvenile (< 18 yrs)

Average number of years incarcerated as an adult 18 yrs)

31

11

26

28

5

41

5

481

16

25

35

4

15

6

6

32

7

9

19

39

28

1.8

1.2

170
over 400 drug-free and self-help substance abuse treatment and

rehabilitation agencies that use the TC modality. (See table 2 for results.)

Eleven agencies reported specialized programs for women and children.

Those eleven were surveyed again in 1991 to obtain more indepth

information on the specific program components and any research being

conducted on this population.

This survey revealed the following:

1.

2.

3.

4.

5.

6.

7.

8.

There were a wide variety of program components in response to

women’s needs (e.g., individual and group counseling, academic and

vocational training). All programs surveyed also included children in

the therapeutic process, some through outpatient services and some

residentially.

Research and evaluation differ tremendously from program to

program, making it difficult to conduct a national evaluation on

women’s and children’s programs.

Length of programs ranged from 6 to 30 months, with the average

being 12 to 18 months.

Program size ranged from 5 to 20 women.

All programs included parenting and training classes, with many

hands-on opportunities.

All programs addressed specific women’s issues both educationally

and therapeutically-some in women-only groups and some in mixed

settings with male participants, family members, and others.

Two programs included special programming for the dually

diagnosed.

Most programs reported that women with children seem to have more

severe histories of drug abuse than their male counterparts, and they

exhibit a greater diversity of multiple needs (e.g., physical and

psychological health, education, vocation). Concern was expressed

regarding whether these needs were being addressed, and whether

women coming into treatment with children were even more

171
dysfunctional than the women traditionally seen in TCs who are either

childless or whose children are placed elsewhere.

In response to issues such as longer criminal histories, severe sexual

histories, and dysfunctional parenting, many programs have developed

special curricula. These curricula include a variety of treatment

components and methods (such as video feedback, seminars, groups,

retreats, and workshops) provided in women-only and mixed group

settings. For example, one area that has gained attention is the need for

parenting education. Substance-abusing women generally are not

equipped to provide positive role models for their children; often they

model dysfunctional behaviors that later may be manifested in their

children through delinquency and substance abuse (Feldman et al. 1987;

Hawkins et al. 1985). The effects of maternal interactions on their

children’s social and emotional development have been documented over

many years. Bowlby (1966) demonstrated a relationship between

maternal deprivation and the development of antisocial personality

disorders in their children. Substance-abusing women often neglect their

children (physically and emotionally) while using substances or when

they are acquiring the substances. Such neglect can interfere with the

development of mother and child bonding and attachment.

In addition, the child who has been exposed prenatally to substances

often exhibits behavioral characteristics that are difficult to cope with and

very demanding of parents. These children often are difficult to comfort,

and they move erratically and quickly from one state to another (e.g.,

sleeping to total hysteria with no period of quiet alertness exhibited by

most infants) (Kronstadt 1991). When a mother’s attempts to quiet her

child consistently fail, this is often interpreted by the mother as the child’s

rejection of her or as a reflection of her inadequacy as a parent. Such

maternal thoughts and emotions can inhibit the attachment process,

placing an emotional distance between child and mother.

These women need an opportunity to learn appropriate parenting skills

and to interact with other women who have shared similar experiences

and feelings. The need for parenting programs within substance abuse

programs was mentioned by each agency contacted in the Amity survey

mentioned above. The programs described in the survey generally

contained both classroom-type education and hands-on mother and child

interactions under the supervision of trained staff.

172
A second area that demands attention is the function of sexuality and

relationships and their impact on drug use (Mullen and Arbiter 1991).

Not only do women (and men) in treatment often have severe sexual

histories in terms of abuse, it is thought that those negative sexual

experiences have an impact on drug use (Silbert et al. 1982; Testa 1991).

Moreover, relapse often is related to failed relationships, especially for

women. Gilligan (1982) noted that women define themselves and their

sense of worth in terms of relationships. At Amity, it is considered

important that both men and women address the following issues related

to their sexual history: (1) women who had abortions and the men who

were responsible; (2) women who prostituted and men who used

prostitutes; (3) women and men who molested children or were molested

themselves; (4) women and men who were raped or who raped;

(5) homosexual experiences; (6) initial sex education; and (7)

introduction to pornography.

At Amity, it is believed that sharing sexual histories creates a sense of

community among women. Common sexual history creates a stronger

sense of connection between women than any other variable, including

race, age, or drug history (Arbiter 1991).

EFFECTS OF WOMEN’S PROGRAMMING ON THE GENERAL

TC ENVIRONMENT AND TREATMENT OUTCOMES

Length of stay in treatment is one of the most consistently cited factors

that affects posttreatment outcomes (Simpson and Sells 1982). Caton

House in Philadelphia reported various influences on the length of stay,

originating from both client and programmatic characteristics. The client

characteristics associated with increased length of stay were increased age

(over 25 years old), higher education (high school, GED, or better), fewer

children (0 to 2), and those who were less likely to have suicidal ideation

before or during the program. The program influences that correlated

with increased length of stay included: (1) low turnover of directors;

(2) decreased levels of confrontational therapy (part of the typical TC

approach to therapy); (3) provision of more nurturant and affirmative

support; (4) input from the participants in developing and updating their

own treatment plans; (5) peers who have graduated from the program

acting as role models; and (6) activities to encourage friendships and

bonding among the women.

173
One factor mentioned repeatedly throughout the 1991 TC survey was the

importance of women’s programming and its impact on the entire

environment. For example, the Amity staff have expressed the feeling

that increased emphasis on women’s issues and participation of more

women in the environment have increased the safety level for selfdisclosure for all participants (Stevens et al. 1989). Since self-disclosure

is one of the key tools for change in TCs, this is an important element to

explore.

Length of stay in treatment also was impacted by the introduction of

specialized women’s programming. Table 4 shows comparative lengths

of stay for men and women before and after such programs were

implemented. The average length of stay for both men and women

increased in 1981, after the specialized women’s programming began.

A second indicator of change is the degree of participation around family

issues that men engage in during treatment. Since the initiation of

specialized women’s programs, it has been observed that many male

participants began to take increased responsibility for their own children.

For example, fathers in treatment began initiating correspondence with

their children after years of silence. Requests for visitations with their

children also increased (Stevens et al. 1989).

COST-EFFECTIVENESS OF SPECIALIZED PROGRAMMING

A variety of specialized programs for women have had positive results

that have been documented over time (Hughes et al. 1991; Stevens et al.

1989). In today’s world, however, these positive results must be judged

against the cost of providing such services.

Several areas must be taken into consideration when determining the

cost-effectiveness of specialized women’s programming. Medical costs

to society have increased drastically in recent years. These costs include

both medical care and insurance rates. Although substance abuse is not

the only cause for these escalating costs, it is certainly one contributing

factor that cannot be ignored.

Substance abuse has impacted medical costs in several ways; 8 of the

15 hospitals surveyed by the Select Committee on Children, Youth, and

Families reported an increase in “boarder” babies (i.e., babies abandoned

174
TABLE 4. Amity gender differences in length of stay (LOS) by number

of days

Year

Men

Admitted LOS

Women

Admitted LOS

1974 18 105 7 57

1975 35 80 12 18

1976 82 120 18 48

1977 113 86 29 72

1978 117 103 16 94

1979 62 80 13 81

1980 NA NA NA NA

1981 84 143 11 222

1982 58 173 18 376

1983 64 311 18 259

1984 79 216 29 224

1985 95 282 30 270

1986 64 326 31 261

1987 53 297 37 279

1988 89 272 42 231

1989 71 238 39 257

NOTE: In 1981, a female director was hired, female staff were hired,

and all staff were educated in basic assumptions of the TC. In

1983, a women’s advocate was hired. In 1984, a mothers’ and

children’s program was established. In 1986, the mothers’ and

children’s program was closed.

in the hospital by their mothers) (Gittler and McPherson 1990). This is

one facet of the economic burden of drug addiction that falls on society

rather than on the drug-addicted mother herself. The medical costs of

dealing with these drug-exposed infants are staggering. The average

cost for a full-term infant requiring 10 days of nonintensive care

hospitalization for symptoms of drug exposure is $6,000. This figure can

increase to $135,000 for a drug-exposed infant requiring intensive care

over several months (Kronstadt 1991).

175
In addition to the cost of caring for drug-exposed infants, substanceabusing women also often require expensive medical interventions due to

long periods of neglect (e.g., no physical exams, poor nutrition, and highrisk behaviors such as drug injection or prostitution). Due to the poverty

level of many such women, the medical costs incurred often are paid for

through Government-subsidized medical care (Beschner and Thompson

1981; Gaudenzia, Inc., unpublished data; Kronstadt 1991).

A second area of financial impact to society is the cost of criminal

activity. Incarceration generally costs between $60 and $70 per day, with

costs increasing as the need for security increases (Gaudenzia, Inc.,

unpublished data; Glider et al., unpublished data). When compared to the

costs of a TC, often 25 percent to 50 percent less than the above figures,

the expense of not providing treatment becomes evident. In addition,

calculation of the cost of criminal behavior also must include the

expenses incurred by the taxpayer to support the system of law

enforcement and prosecution. A third cost is that directly translated to

the consumer through higher prices created to cover the costs of

shoplifting.

The need for foster care for children of substance abusers also is

escalating at an incredible rate. A study released by the National Black

Child Development Institute in April 1991 reported that 36 percent of

children in foster care across five urban cities had substance-abusing

parents. Costs for the specialized foster care required by many drugexposed children have been estimated at $23,000 per year in Philadelphia

(Gaudenzia, Inc., unpublished data), The annual placements of drugaffected babies in New York City have increased from 750 to 3,500 due

to crack, The costs of this foster care have more than doubled, from

$320 million to $795 million (Sofer, unpublished data). Similarly, Los

Angeles County reported a 500-percent increase in foster care placements

for children of substance abusers between 1981 and 1987 (Gittler and

McPherson 1990).

Even the educational system is feeling the financial burden of children of

substance-abusing parents. Johnson and colleagues (1990) stated that the

educational cost of a child in a regular classroom is approximately $3,500

annually, while the cost of educating a child in a pilot project for drugexposed children in Los Angeles is $15,000 annually. The Florida

Department of Human Resources estimated that it will cost $40,000

annually to prepare a crack-exposed infant for school. When all of these

costs are taken into consideration (medical, legal, educational, social), the

176
evidence seems heavily weighted in favor of the cost-effectiveness of

treatment for substance-abusing women.

SUMMARY AND CONCLUSIONS

The following major points can be summarized from this chapter:

1.

2.

3.

4.

Women and men have different characteristics and treatment needs;

therefore, programs must be responsive to the specialized needs of

women.

It appears that the presence of women in the TC environment as staff

role models and program participants enhances treatment outcomes

for both men and women, as evidenced by the LOS statistics and

behaviors described previously.

Preliminary data from surveyed programs that provide services to

mothers and children show positive effects for recovery (alcohol and

drug use, parenting skills).

Conclusive data on women’s and children’s programs have not yet

been generated, since many of these programs have been established

within the last few years.

FUTURE PROGRAMMING AND RESEARCH

RECOMMENDATIONS

There are several paths of research suggested by this review. One issue

mentioned by several of the programs surveyed by Amity is the

importance of determining whether treatment for women is more

effective when only women are treated, or when men and women are in

treatment together. Women appear to benefit from different treatment

modalities than men have used (e.g., less confrontational), and their

sexual history makes trusting men difficult. However, learning to trust

men again is necessary for women’s emotional health. This suggests an

initial TC experience with women alone, followed by interaction with

men when enough ego strength has been developed to optimize recovery.

An interesting study might examine outcome effects from such a

treatment strategy. However, outcomes for children must not be ignored.

Longitudinal studies of outcomes for children should be examined,

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considering both children who were with their mothers in treatment and

children whose mothers underwent treatment without them.

With the growth in demand for substance abuse treatment, it is

increasingly important to determine the costs and benefits of treatment

versus alternatives such as incarceration or nontreatment. Within the

treatment alternative, such variables as the optimal LOS should be

examined for cost-efficiency.

Process evaluation remains a much discussed but underdescribed area

requiring more research. The following questions in this area need to be

answered: (1) which staff characteristics predict program effectiveness;

(2) what program components are required to achieve successful

posttreatment outcomes; (3) how are important TC concepts such as selfdisclosure and peer role models measured; and (4) to what degree are the

critical elements of the TC present, such as the challenging of held

values, the playing of different roles, the provision of sustained

responsibility, and the availability of credible teachers.

Finally, the measurement of outcome variables is the linchpin upon which

all funding rests. Such outcome variables as alcohol and drug use,

employment, criminal behavior, quality of life, effective parenting, and

the quality of relationships need to be determined.

REFERENCES

Abramovitz, M. Regulating the Lives of Women: Social Welfare Policy

from Colonial Times to the Present. Boston: South End Press, 1988.

Arbiter, N. “Cultural Diversity: A Tool or Barrier?” Paper presented at

the National Council of Juvenile and Family Court Judges’ Program

on Drug Exposed Infants and Their Mothers, Reno, NV, April 11,

1991.

Beschner, G., and Thompson, P. Women and Drug Abuse Treatment:

Needs and Services. National Institute on Drug Abuse Research

Monograph. DHHS Pub. No. (ADM)81-1057. Washington, DC: Supt.

of Docs., U.S. Govt. Print. Off., 1981.

Bowlby, J. Maternal Care and Mental Health. New York: Schocken,

1966.

De Leon, G. Psychopathology and substance abuse: What is being

learned from research in therapeutic communities. J Psychoactive

Drugs 21(2):177-188, 1989.

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De Leon, G. The Therapeutic Community: Study of Effectiveness.

National Institute on Drug Abuse Research Monograph. DHHS Pub.

No. (ADM)84-1286. Washington, DC: Supt. of Docs., U.S. Govt.

Print. Off., 1984.

Densen-Gerber, J., and Rohrs, C. Drug-addicted parents and child abuse.

Contemp Drug Probl 2:683-695, 1973.

Densen-Gerber, J.; Weiner, M.; and Hochstedler, R. Sexual behavior,

abortion, and birth control in heroin addicts: Legal and psychiatric

considerations. Contemp Drug Probl 1:783-793, 1972.

Edelstein, S.; Kropenske, V.; and Howard, J. Project T.E.A.M.S. Soc

Work 35(4):313-318, 1990.

Feldman, R.; Stiffman, A.; and Jung, K. Children at Risk: In the Web of

Parental Mental Illness. New Brunswick, NJ: Rutgers University

Press, 1987.

Gilligan, C. In a Different Voice. Cambridge, MA: Harvard University

Press, 1982.

Gittler, J., and McPherson, M. Prenatal substance abuse. Child Today

19(4):3-7, 1990.

Hawkins, J.; Lishner, D.; and Catalano, R. Childhood predictors and the

prevention of adolescent substance abuse. In: Jones, C.L., and Battjes,

R.J., eds. Etiology of Drug Abuse: Implications for Prevention.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1985.

Hughes, P.; Neri, R.; Storr, C.; Sicilian, D.; and Urman, C. “Retention of

Cocaine Using Mothers at Par Village.” Paper presented at Substance

Abuse and Pregnancy: Children Deserve Better Conference,

Clearwater, FL, 1991.

Johnson, H.; Glassman, M.; Fiks, K.; and Rosen, T. Resilient children:

Individual differences in developmental outcome of children born to

drug abusers. J Genet Psychol 151(4):523-539, 1990.

Kronstadt, D. Substance Abuse During Pregnancy-Impact on Mothers

and Their Children: A Guide to Resources. Rockville, MD: Office for

Substance Abuse Prevention, 1991.

Moss, K. “Coalition on Alcoholic and Drug Dependent Women and Their

Children: State Legislative and Policy Proposals.” Unpublished report,

1990.

Moyers, W. A World of Ideas. New York: Doubleday, 1989. pp. 140-155.

Mullen, R., and Arbiter, N. Introductory Training on the Teaching and

Therapeutic Community for Drug Abusing Offenders. Tucson, AZ:

Amity Publishing and Media Arts, 1991.

National Institute on Drug Abuse. Data from the Client Oriented Data

Acquisition Process (CODAP), Series D., No. 13. Rockville, MD:

National Institute on Drug Abuse, 1979.

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Palley, R. Tough cure for the ravages of crack: Special report on women

and children alone. Philadelphia Daily News, February 16, 1991. pp.

18-25.

Rist, M. The shadow children: Preparing for the arrival of crack babies in

school. Res Bull 9:1-6, 1990.

Rom-Rymer, J. “An Empirical Assessment of Mowrer’s Theory of

Psychopathology Applied to a Therapeutic Community.” Ph.D. diss.,

Florida State University, 1981.

Silbert, M.; Pines, A.; and Lynch, T. Substance abuse and prostitution.

J Psychoactive Dogs 14(3):193-197, 1982.

Simpson, D.D., and Sells, S.B. Effectiveness of treatment for drug abuse:

An overview of the DARP research program. Adv Alcohol Subst

Abuse 2(1):7-29, 1982.

Stevens, S. “Special Issues Concerning Women in Alcohol and Drug

Abuse Treatment.” Paper presented at the Interagency Council on

Alcoholism and Drug Abuse, Tucson, AZ, April 8-10, 1988.

Stevens, S.; Arbiter, N.; and Glider, P. Women residents: Expanding their

role to increase treatment effectiveness in substance abuse programs.

Int J Addict 24(5):425-434, 1989.

Stevens, S.; Erickson, J.R.; and Estrada, A.L. Characteristics of female

sexual partners of injection drug users in southern Arizona:

Implications for effective HIV risk reduction interventions. Drugs Soc

7(3/4):121-134, 1993.

Testa, M. Sexual abuse in past makes booze inviting. J Drug Alcohol

Depend 15(4):18, 1991.

Wasnick, C.; Schaffer, B.; and Bencivengo, M. “The Sex Histories of

Fifty Female Drug Clients.” Paper presented at the National Alcohol

and Drug Coalition, Washington, DC, September 15-19, 1980.

AUTHORS

Sally J. Stevens, Ph.D.

Director of Research

Peggy J. Glider, Ph.D.

Senior Research Associate

Amity, Inc.

47 East Pennington

Tucson, AZ 85701

180
Therapeutic Communities in

Prison

Harry K. Wexler and Craig T. Love

INTRODUCTION

Community-based therapeutic communities (TCs) have been found to

have a positive effect on reducing the criminal activities and drug use of

clients who complete their programs (De Leon et al. 1972; Simpson

1979, 1980). It is important to note that these studies included many

clients with criminal histories. De Leon (1984) noted that the longer the

client remained in treatment, the better the outcome. This time in

program (TIP) effect was investigated by Wexler and colleagues (1990)

and Wexler and Williams (1986a) in evaluating the Stay’n Out TC

program in the New York State prison system.

A major aim of the Stay’n Out program evaluation was to assess the TIP

effect in a prison-based TC, where clients remained longer than in

community-based programs. One important finding of the studies

(Wexler and Williams 1986a; Wexler et al. 1988a) was a replication of

the TIP effect, clearly demonstrating the effectiveness of TCs in prison.

Subsequently, a federally funded program (Project REFORM)

successfully established drug treatment programs based on the Stay’n Out

model in several other State systems (Wexler et al. 1991).

TCs incorporate certain common features: isolation from the rest of the

community, use of ex-offenders and ex-addicts as staff, development of a

safe environment, use of confrontation and support groups, clearly

specified rules and sanctions, and the development of prosocial attitudes.

As a treatment setting, TCs immerse clients in a highly structured and

supportive environment. In a safe, but public, place, peers and treatment

staff challenge clients to confront their problems directly and take

responsibility. A TC is a place where clients live and often work for an

extended time (often a year or longer) away from negative community

influences.

In a prison setting, TCs operate in the same way. Inmates are housed

separately from the rest of the prison population. The TC programs focus

on criminal behavior, substance abuse, sexual abuse, and issues related to

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living in the unit. While most prison activities stress security and custody

issues, the TC emphasizes the inmates’ personal growth and provides a

safe place for free expression.

From a prison administrator’s perspective, it can be useful to isolate

inmates participating in a TC. The TC residents tend to be self-regulating

and motivated to avoid conflict and cooperate with correctional staff. At

a minimum, inmates are occupied; at the maximum, TC programs

provide effective rehabilitation.

This chapter examines the history of TCs in prison, documents the

empirical evidence of their effectiveness, describes a national technical

assistance project (Project REFORM) that has helped establish new

prison TCs, and offers guidelines for successful implementation of a TC

behind prison walls.

EARLY HISTORY OF TCs IN PRISON

Until recently, few data were available from prison TC outcome

evaluations (Camp and Camp 1989). The study of the early history of

TCs in prison was limited to anecdotal information such as that offered

by Camp and Camp (1989).

TCs in the Federal Prison System

The TC approach was attractive to Federal Bureau of Prisons (BOP)

officials because of the development of the unit management system.

The unit management system organizes institutions into functional units;

each unit is managed by a unit manager who supervises the unit team

(Levinson 1980). This approach makes it possible to manage a large

prison as if it were several smaller institutions, each with its own case

management team, disciplinary committee, and treatment staff.

Under the unit management system, it was easy to make one of the units a

TC with its own program plan. Earlier drug treatment programs had been

funded by provisions in Title II of the Narcotic Addiction Rehabilitation

Act (NARA), which authorized Federal judges to commit convicted

felons to prison drug treatment programs. The length of time served

depended on the individual inmate’s progress in rehabilitation.

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An early NARA drug treatment site was at the Terminal Island, CA,

Federal facility. This treatment program included a residential program

that was a precursor to the TC, as well as psychotherapy and counseling,

biofeedback training, a transactional analysis (TA) group, and

educational, vocational, and social activities. Drug treatment aftercare

planning was part of the inmate’s prerelease programming. Although the

program did not involve control groups, internal reports suggested betterthan-average performance.

Marion, IL. One of the first and best known prison-based TCs was

established in 1969 at the Federal BOP’s maximum security institution in

Marion, IL. The program, called Aesklepieion, was developed and

implemented by Dr. Marty Groder, a BOP psychiatrist. The Marion

facility recently had been opened to house inmates transferred from

BOP’s original maximum security facility, Alcatraz. It is noteworthy that

the Aesklepieion program was implemented in the most secure facility in

the Federal BOP, which housed the most difficult inmates in the Federal

prison population. This contrasts with most early prison programs that

were offered in low-to-minimum-security facilities. Because inmates in

those facilities are most likely to avoid involvement with the criminal

justice system after they are released, programs in less secure facilities are

ensured of the appearance of success.

“Convict code” is a general term referring to inmate resistance to

communicating with staff, supporting any staff or administration activity,

and sabotaging as many aspects of the prison operation as possible. In

many institutions, the convict code is physically enforced among the

inmates. The strong convict code presented a major barrier to the

development of the new culture provided by the TC. Aesklepieion staff

developed effective strategies to combat this resistance. A key feature of

the Aesklepieion program was that inmates could “call a game” on

another inmate or a staff member, meaning that the individual was being

confronted or challenged about a particular topic. This feature

empowered inmates to take action, in contrast to the usual restricted

prison situation. It also fostered an openness in communication between

TC staff and inmates.

A second important feature of the Aesklepieion program that may have

contributed to its success was the use of transactional analysis (Berne

1961; Harris 1967) and its special language. Code words and phrases

(e.g., little professor, replaying tapes) added to the special nature of the

program and gave the participating inmates a special form of

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exclusiveness in an environment that greatly limits individuality.

Membership in such an exclusive group can be very attractive to prison

inmates. The program also was attractive to prisoners because

participation in the program enhanced the likelihood of a favorable

review by the parole board. Few similar opportunities were available to

the inmates of the Marion facility.

The features that made the Aesklepieion program attractive to inmates

also made it a source of conflict. First, the program’s special language,

privileges, and staffing created mistrust among staff and inmates who

were not involved. Second, participating inmates were isolated from all

other inmates because of their daily Aesklepieion activities and because

most inmates had jobs in the same area of the institution. Third, inmates

had too much control over the unit; the fact that they could confront staff

as well as fellow inmates made working in the unit a threatening process

for some staff. Finally, these factors were exacerbated by the general

emphasis on security in this maximum security prison, making programs

a low priority.

The lack of communication between TC staff and the rest of the

institution made it difficult for other staff to understand the program and

its features, and general mistrust evolved. The program eventually closed

because of a combination of administration changes and difficulties in the

institution itself. No data are available that provide an objective

evaluation of the program’s effects on outcome.

Federal Correctional Institution (FCI), Oxford, WI. During the

evolution of the Marion TC, several other offshoot programs were

developed at other Federal and State prisons. Inmates were used as staff

in some State systems and as peer counselors in other State and Federal

programs. For example, the program at FCI Oxford was started in 1974,

just as the institution opened as a Federal facility. FCI Oxford was

opened under a unit management model. The new TC was an

Aesklepieion program modeled after the Marion unit, and it was

implemented by former Marion staff and a core group of Marion inmates.

The Marion inmates established the TC culture and set up the program at

Oxford, which continued for nearly 5 years.

The FCI Oxford program allowed inmates a central role in the

recruitment and selection of inmate participants within the institution.

Inmate graduates conducted classes for the general prison population on

the basics of TA. Inmates referred to the classes as “TA-101” and

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“TA-102,” identifying them as basic courses. Inmate instructors used

these classes to identify others in the general population they deemed

suitably motivated to participate in the TC program. While the selection

process was conducted by staff, inmates made specific recommendations

as part of the screening process.

Inmates at Oxford, like Marion, were enthusiastic about entering the

program, and a waiting list was developed periodically. Some of the

incentives for entering the Oxford TC included extra privileges. The

program featured premium housing in comparison with the rest of the

institution, and the unit was open only to participants. In general,

participants were separated from the rest of the institution and had little

contact with other staff and inmates. The program survived several

administrative changes and turnover of inmates until it was closed in

1979.

Other Federal Programs. Other programs were developed with the use

of Marion and Oxford inmates as core members of the new unit. In 1977,

for example, an attempt was made to develop a TC at FCI Miami by

using inmates from the Oxford facility. That program was short lived

when the facility’s mission and the characteristics of the prison

population changed. The Miami facility soon housed a large number of

major drug offenders and immigrating Cubans because of the growing

drug-related criminal activity in the region and the large number of

Cuban mental patients, prisoners, and other “undesirables” sent by Fidel

Castro.

Other Federal facilities that included TCs were listed by Camp and Camp

(1989) as follows: Ft. Worth, Tallahassee, Terre Haute, Terminal Island,

Danbury, FCI Miami, and FCI Seagoville, TX. All of these programs

were closed eventually. Some TCs closed when it was found that the TC

inmates were involved in dealing and using drugs. The corruption of the

units was engendered by the staffs loss of control over the program. In

most of these programs, the units were closed to outsiders; not even staff

from other units or programs entered the unit very often. Further,

inmates were allowed to manage many aspects of the unit with almost no

supervision. At FCI Seagoville, for example, several inmates in the TC

screened program candidates; eventually, they began selling admissions

to the unit. These are prime illustrations of the consequences of allowing

inmates too much control over their own programs.

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The Demise of Federal TCs. The Federal initiative in the use of TCs

in prison, along with all other programs, declined in the late 1970s.

Camp and Camp (1989) attributed the decline in TCs to a loss of support

for TCs in the Federal BOP during that period. There also was general

dissatisfaction with all types of treatment programs throughout the

corrections field during the late 1970s. This disillusionment came in the

wake of a general loss of confidence in treatment programs crystallized

by Martinson’s (1974) Public Interest paper. That paper was read widely

by BOP officials and became one of several bases for a general trend

away from providing treatment to inmates.

The basic message of the literature review on prison treatment programs

(Lipton et al. 1975) was that there was little evidence that programs

worked, and more carefully designed evaluation studies were needed.

However, the review frequently was misinterpreted to mean that existing

programs were ineffective, rather than the actual conclusion that the

studies could not show that such programs do work. Subsequently, the

Federal BOP placed more emphasis on less intense treatment modalities

such as educational and vocational programs. Rehabilitation programs

and ideas were no longer seen as a priority in the BOP mandate. Most

criminal justice agencies and academic studies turned to concerns about

“just desserts” and the control of prisoners. Correctional research

innovations were directed toward such inmate management notions as

“humane incarceration” (Morris 1974) and no longer toward

rehabilitation goals (Love and Ingram 1982; Love et al. 1986).

Treatment programs in general lost administrative support; most were

discontinued or reduced in scope and intent. The Federal BOP’s earlier

emphasis on providing intensive treatment for criminal behavior and

drug/alcohol use was discontinued. Unfortunately, none of the TC

programs had compiled outcome data on their impact on inmates’

subsequent criminal or drug-using behavior. In the absence of

appropriate data, support for resource-intensive TCs diminished among

administrators and employees. The general feeling was that TC programs

did not work anyway.

The lessons learned from the early TCs in Federal prisons support the

recent applications of the TC approach to prison-based interventions

such as Stay’n Out and Project REFORM. First, the program managers

must orient the prison staff, administration, and inmates to establish clear

expectations about the TC and to prevent ambiguity and misunderstanding about the program and its implementation. Second, TC staff

186
should not be insulated from the rest of the institution; prison staff should

receive cross-training in all programs offered in the facilities. Third, the

potential for alienation between security and treatment staff must be

addressed immediately and appropriately. The program staff should

incorporate security concerns in the TC program and operations. Fourth,

the TC staff must retain sufficient control over the program.

TCs in State Prison Systems

The early history of TCs in State prison systems exhibits many of the

same problems identified in the Federal prison system: programs out of

control, staff mistrust, and poor communication. Many of the State

prison TCs examined by Camp and Camp (1989) were derived from the

Aesklepieion TC at Marion. Former inmates from Oxford and Marion

were employed to develop and manage these TCs. For example, the

Arkansas Department of Correction established a TC in a work release

facility using the Aesklepieion model, and former graduates of the

Marion program served as TC staff. The program endured similar

resistance to that experienced in the Federal facilities but finally was

accepted by both the staff and administration. However, the status of the

program was weakened substantially after correctional staff found drugs

and alcohol on the unit. The final straw came when the director of the

program was arrested on drug and alcohol charges.

Several other State prison systems used the TC as a treatment modality.

The Connecticut and Virginia State prison systems opened TCs based on

the Aesklepieion model. These programs were closed because of

increasing prison populations and the need to provide less expensive

programs for more inmates. According to Camp and Camp (1989), the

TCs also were targeted because they failed to maintain an open line of

communication with the rest of the institution. Finally, TC staff members

were not well accepted by security staff.

In addition, other States implemented less intense TC programs that were

discontinued because of increasing inmate populations, reduced

resources, and resistance from key administration officials. None of these

programs provided outcome evaluations or collected data that would be

useful to assess their integrity or effectiveness.

One study did demonstrate the efficacy of TCs as a suitable treatment

approach for prison inmates (Nash 1973). Nash evaluated seven

prison-based drug abuse treatment programs, using changes in arrest rates

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as a major dependent measure. This evaluation assessed changes in arrest

rates for a total of 173 inmates who attended seven prison-based

programs. Four of these programs were TCs based on the original

Synanon model, two were counseling programs, and one was a drug-free

residential program. Although the original study by Nash did not find

significant differences in arrest rates between any of the programs and

treatment comparison groups, a more extensive analysis by Des Jarlais

and Wexler (1979) found that two of the four TCs did significantly better

than the comparison groups.

RECENT HISTORY OF TCs IN PRISON

Stay’n Out

The Stay’n Out program was the first in-prison TC to be extensively

evaluated (Wexler et al. 19886). Stay’n Out is located in two New York

State prisons: one for men at the Arthur Kill Correctional Facility on

Staten Island, and the other for women at the Bayview Correctional

Facility in Manhattan. The rationale for the development of Stay’n Out

was based on the growing research on community-based TCs, according

to Wexler and colleagues (1988b). Community-based TCs are widely

accepted and have been demonstrated to be effective with clients who

have criminal histories (Bale 1979; De Leon 1984; De Leon et al. 1972,

1979, 1982; Holland 1978; Nash 1973; Sells et al. 1976; System

Sciences, Inc. 1973; Wilson and Mandelbrot 1977).

Evaluation of the Phoenix House program (De Leon 1984; De Leon et al.

1979) provided direct support, because the Stay’n Out model is based on

the Phoenix House program. Not only were the results of the Phoenix

House evaluation supportive of TC effectiveness in a 5-year followup

study, but it was found that successful outcomes (i.e., reduced crime,

reduced substance abuse rates, and increased employment) were related

to the time spent in treatment (De Leon et al. 1979, 1982; Simpson 1979,

1980). This TIP factor has been the subject of several subsequent

research studies.

The Stay’n Out program was implemented in July 1977 as a modified,

classic hierarchical TC. It began at a time when many other in-prison TC

programs were closing. Program capacity was 120 inmates when this

research was conducted. Residents lived in dedicated housing units

separate from the rest of the prison population. They had contact with

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prisoners in the general population only when off the TC unit (e.g., at the

cafeteria, infirmary, or library). The Stay’n Out staff was comprised

mostly of ex-addicts with TC experience. The employment of ex-addicts

as counselors is consistent with the practice of community-based TCs.

One important function of the ex-addicts, particularly among the prison

population, was to serve as role models for the clients.

The evaluation of the Stay’n Out TC offered a timely opportunity to

gather new information about the TIP effect noted by De Leon (1984) in

community-based TCs, because Stay’n Out is a prison-based TC. The

TIP effect reported in previous studies was diminished by the high early

dropout rate in the community-based TCs (De Leon et al. 1979). It was

expected that prison inmates would remain in the TC longer and thus

provide a clearer picture of the TIP effect. Inmates were expected to find

participation in the TC program sufficiently attractive to remain as long

as they could. For example, the TC unit provided more desirable housing

(quieter, better maintained) than regular prison units. Further, the TC

offered more activities that reduced the daily boredom of regular prison

routines, provided more special incentives, and offered opportunities to

impress the parole board.

Early research on Stay’n Out showed that the program was successful in

implementing and maintaining a positive TC treatment environment, was

capable of retaining inmates for optimal treatment durations (9 to

12 months), facilitated positive personality changes as assessed by

standard psychological measures (Wexler and Chin 1981), and produced

positive outcomes (Wexler et al. 1985). Wexler and colleagues (1988b,

1990) reported on a more extensive study that examined the effectiveness

of prison-based TCs and assessed the TIP effect. The quasi-experimental

design compared Stay’n Out participants with a group of inmates who

were on a waiting list for the TC and with two groups who participated in

other programs (of varying intensity) in different prisons (milieu and

counseling programs). Male and female inmates who completed the

program between 1977 and 1984 participated in the study. The average

TIP ranged from 5 to 8 months across the four program groups, who

differed significantly in terms of TIP. The total time in prison for the

current sentence generally was longer for males than females. These and

other differences were controlled in the analyses of followup data.

Wexler and colleagues (1988b) reported that the differential outcomes

among the four groups in the study generally were supportive of the

prison-based TC program. The percentage arrested after treatment was

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lowest for the Stay’n Out TC group (26.9 percent) and increased as the

intensity of treatment decreased (to a high of 40.9 percent for the

no-treatment, waiting list group). Among the male study groups, the

Stay’n Out program was substantially more effective in reducing the

percentage arrested than the comparison treatment groups and the notreatment group. However, among those arrested, there were no

differences among the groups in length of time to arrest. Approximately

60 percent of the Stay’n Out TC group received positive parole

discharges, but this rate was not significantly different from the rates for

the other male groups. The female Stay’n Out TC group had the lowest

percentage arrested (17.8 percent) and the highest percentage positively

discharged from parole (77.2 percent); the differences were not

statistically significant.

The TIP effect reported in earlier studies was substantiated in the Stay’n

Out evaluation. In the analyses, participants were divided into five

subgroups according to the amount of time they were in treatment (less

than 3 months, 3 to 5.9 months, 6 to 8.9 months, 9 to 11.9 months, and

over 12 months). Wexler and colleagues (1988b) performed extensive

analyses of the TIP effect on percentage arrested, time until arrest, and

percentage positively discharged from parole. The general pattern in

several analyses was that as time in the Stay’n Out program increased up

to a year, positive parole outcomes increased, followed by less positive

outcomes for those who stayed longer than a year. This pattern was

clearly demonstrated with the time to arrest variable. The mean time to

arrest for clients who stayed in the program for 3 months or less was

approximately 9 months; for clients in the program between 9 and

11.9 months, the average time until arrest increased to 18 months; and for

clients in the program over 12 months, time until arrest decreased to an

average of 14 months.

An even more striking demonstration of the TIP effect was found in the

percentage of participants who were positively discharged. For example,

positive parole discharges for males increased from 49 percent for the

under 3 months group to a peak of 77 percent for the 9 to 11.9 months

group, and then decreased to 57 percent for the over 12 months group.

Similar results were found with female clients. The authors suggested

that inmates who successfully completed the 9 to 12 months of treatment

were optimally prepared for release to the community. The data further

suggest that remaining incarcerated after completing the program may be

demoralizing and detrimental to the client’s postrelease performance.

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Cornerstone

Independent confirmation of the utility of TCs in prison has been

provided by evaluation of the Cornerstone program, a currently active

program described by Field (1984, 1989). Cornerstone is a prerelease

treatment program for alcohol- and drug-dependent offenders, which

opened in 1976 on the grounds of the Oregon State Hospital in Salem. It

consists of a 32-bed residential unit and a 6-month aftercare program.

Cornerstone operates under the joint auspices of the Oregon Divisions of

Mental Health and Corrections. Inmates are referred to the program by

prison counselors if the inmate has a history of substance abuse, qualifies

for minimum security (including the criterion of having 6 to 12 months

left to serve), plans to remain in the State after release, and has no

diagnosis (such as psychosis or sex offender) that would limit the

program’s effectiveness or survival.

Inmates participating in the Cornerstone program have severe histories of

criminal behavior, as was the case in Stay’n Out. In 1984, for example,

Cornerstone clients had an average of about 7 felony convictions and had

served more than 7 years in prison. This group also included very

experienced drug users, starting substance abuse at the mean age of

12 years. Nearly all participants (95 percent) had histories of polydrug

abuse.

The Cornerstone program, like Stay’n Out, is based on the classic TC

concept. There is a clearly articulated set of rules with consequences for

failure to comply (cardinal rules prohibit behaviors such as using drugs or

resorting to violence), inmates participate in the operation of the program,

and the program employs social learning and self-help concepts. The

violation of cardinal rules is grounds for dismissal, but all other rules are

seen as learning opportunities and are sanctioned by requiring the inmate

to perform more appropriate behavior. Participants also earn privileges

(especially increased freedom) by exhibiting good behavior. Program

components include family meetings, encounter groups, classroom

instruction on skills, individual counselor sessions, and participation in

Alcoholics or Narcotics Anonymous. Completion of the residential

program is followed by a 6-month aftercare phase in which residents are

free in the community but maintain contact with Cornerstone staff, parole

officers, and outpatient drug treatment staff.

Two outcome evaluation studies of Cornerstone (Field 1984, 1989)

demonstrated the effectiveness of a TC in a modified prison unit on State

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hospital grounds. The overall results of Field’s research are similar to the

findings of the Stay’n Out program. The first evaluation (Field 1984)

examined 3-year outcomes for all inmates who graduated from

Cornerstone between 1976 and 1979. The graduates were compared with

three groups: Cornerstone dropouts (with less than 1 month stay); all

Oregon parolees with a substance abuse history; and a sample of parolees

from Michigan. There were no statistical differences among

demographic and background characteristics for the program graduates

(n = 144), the dropouts (n = 27), and the sample of Michigan offenders

(n = 217). The only prior differences among the groups was the Oregon

parolees (n = 179) who had significantly less severe histories of substance

abuse and crime than the Cornerstone graduates. The four groups were

compared on two measures of outcome: percentage not returned to

prison and percentage not convicted.

The 3-year followup of Cornerstone graduates clearly showed that the

graduates exhibited significantly better postrelease performance than any

of the comparison groups. Although the Cornerstone graduates had more

severe criminal histories, 71 percent of program graduates were not

reincarcerated 3 years after release in comparison to 63 percent of Oregon

parolees. Similarly, although slightly more that half the program

graduates were not convicted of any crimes, only 36 percent of the

Oregon parolees were not convicted of any crimes. Program dropouts

fared even worse, with only 26 percent avoiding reincarceration and

15 percent not convicted of any subsequent crimes.

A second study of Cornerstone (Field 1989) not only substantiated the

effectiveness of the Cornerstone TC but also found a TIP effect similar to

that reported by Wexler and colleagues (1988b). Field’s study, based on

a much smaller sample than Wexler’s (n’s range from 43 to 65),

compared a group of Cornerstone graduates (average stay = 11 months)

with three groups of clients who did not graduate but spent more than

6 months, 2 to 6 months, or less than 2 months in the program. The three

measures of recidivism that were assessed in the 3-year followup were

arrest, conviction, and reincarceration rates.

The TIP effects reported by Field (1989) were consistent across all three

measures. The no-arrest rate (37 percent) of graduates during the 3-year

period following release was superior to the rates of dropouts in the 6 or

more months and 2 or less months categories (21 percent and 8 percent,

respectively). Just over 50 percent of the Cornerstone graduates were not

convicted of a new crime within the 3-year period, versus 28 percent for

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residents who did not graduate but remained for over 6 months. Only

11 percent of those who were in the program for less than 2 months were

not convicted.

Reincarceration rates followed a similar pattern, with nearly three-fourths

of the graduates not incarcerated during the 3 years after release, versus

37 percent of those who did not graduate but remained in the program for

more than 6 months, and 15 percent of those who were in the program for

less than 2 months. Clearly, length of stay in the program had a positive

effect on outcomes of prison TC programs.

Wharton Program

The TC approach also has been successfully employed with youthful

offenders in the Wharton Tract Narcotics Treatment Program (Platt et al.

1980). The New Jersey TC opened in 1970 and housed 45 youthful

offenders (over 19 years of age) in a former State forestry camp. The

Wharton program included three stages: evaluation, intensive therapy,

and a transition phase to ease residents back into the community.

Treatment interventions included guided group interactions, group

interpersonal problem-solving, couples therapy, family counseling,

individual counseling, and recreational activities.

Platt and colleagues (1980) conducted a 2-year followup comparing the

outcomes of 160 graduates of the Wharton program with 140 comparison

group members. The latter group were people who met the criteria for

the program but did not enter the program for a variety of reasons. There

were no background differences between the two groups. The TC

participants performed significantly better on recidivism measures. They

had a significantly lower reincarceration rate (18 percent) than the

comparison group (30 percent) and significantly fewer arrests in the

2-year period (51 percent were arrest-free) than the comparison group

(34 percent).

Summary of Recent History of TCs In Prison

The effectiveness of prison TCs was substantiated by evaluation research

during this period. The following evaluation findings are consistent with

the conclusions drawn about the Stay’n Out program by Wexler and

colleagues (1988b).

193
1. The TC is a viable approach that can be successfully administered

within a prison environment.

2. The TC approach has been demonstrated to have a significant impact

on reducing recidivism.

3. The TC approach is more effective than other approaches to which it

has been compared.

4. The greater the time spent in the TC, the lower the recidivism rates.

TCs are maximally effective for inmates who spend 9 to 12 months

in the prison TC.

The Stay’n Out, Cornerstone, and Wharton evaluations provided

convincing evidence that prison-based TC treatment can produce

significant reductions in recidivism rates.

CURRENT STATUS OF TCs IN PRISON

Federal Prisons

The Federal BOP recently has undertaken a major substance abuse

treatment initiative. Murray (1991) reported that 51.7 percent of Federal

inmates have a documented substance abuse problem. The increasing

inmate population (projected to reach 95,000 by 1995) also includes an

escalating number who have been incarcerated for drug offenses.

Currently, 51 percent of Federal inmates are incarcerated for drug

offenses; this rate is projected to reach 69 percent by 1995. Murray

reported that in a recent BOP survey, 43.8 percent of the inmates who

were diagnosed as having a substance abuse problem requested to

participate in drug abuse treatment.

The new BOP approach includes a hierarchy of programs of increasing

intensity. The basic programs include a 40-hour mandatory drug

education program, voluntary drug counseling, 9-month voluntary

residential treatment, and 12-month residential treatment.

The Federal BOP approach presupposes that one treatment program will

not serve all inmates. Instead, programs of various intensities will be

made available for all eligible inmates, allowing them to enter the

programs of their choice. The educational and counseling component

194
employs a relapse prevention model (Marlatt and George 1984; Marlatt

and Gordon 1980), and some programs use a 12-step approach. A

transitional care program, designed to assist the offender in preparing for

continued drug abuse treatment and support after release, is provided for

inmates who complete treatment programs. The Federal BOP currently is

involved in a joint project with the National Institute on Drug Abuse

(NIDA) to assess the efficacy of intense residential treatment programs.

The Federal BOP has acknowledged the influence of Stay’n Out and

Project REFORM in many features of the new Federal program (Murray

1991).

State Prison Systems

Project REFORM. In response to increasing public demands that

something be done about the growing drug problem, State and Federal

legislatures have enacted determinate and mandated sentencing laws,

resulting in a sharp increase in the number of inmates in U.S. prisons.

The number of incarcerated offenders in jails and prisons, numbering

approximately 500,000 in 1984, reached nearly 1.2 million in 1991. A

large proportion of newly incarcerated offenders are involved with drugs

as either users or dealers. Estimates of incarcerated individuals with

drug-related crimes or substance abuse problems range from 70 to

85 percent.

One response to the growing need for in-prison drug treatment programs

was a Bureau of Justice Assistance (BJA) program called Project

REFORM. Project REFORM was designed to help State prison systems

develop corrections-based drug treatment programs (Wexler et al. 1991).

The program was funded through the Anti-Drug Abuse Act of 1986,

which called for substantial new resources for correctional drug treatment

efforts.

Project REFORM (1987-1991) was unique in several important respects.

First, it offered technical support to State prison systems in developing

new programs for their growing populations. This meant that a State

system could use consultants available from Project REFORM to develop

their program. Second, the State prison systems were offered orientation

and training programs as part of Project REFORM. This provided a

vehicle for State systems to profit from the collective experience of other

Project REFORM programs. Third, Project REFORM established an

evaluation procedure as part of the project. Each participating State

system developed a design and data collection procedure to ensure

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meaningful and effective program evaluation. These evaluation

components also were supported with consultation services from Project

REFORM.

State systems that were willing to develop systemwide drug treatment

efforts were selected on a competitive basis. The project began in July

1987, and the first group of States was selected that year. The major

goals of Project REFORM were to reduce the amount of crime and drug

abuse among previously incarcerated offenders after their release.

The Project REFORM program operated in two phases: planning and

implementation. The Department of Justice provided funding to the

States for both phases. The planning phase required the State system to

develop a comprehensive Statewide plan for their prison-based drug

treatment programs. Planning was funded by a BJA Federal grant.

Project REFORM staff used a network of technical assistance experts

who advised States about promising drug treatment programs and

strategies and how to apply them to their specific circumstances. For

States that successfully completed the first stage, funding was supported

to implement selected segments of the programs.

Project REFORM made it possible for 11 State prison systems to share

resources in developing drug abuse treatment programs, complete with an

evaluation component. Project guidelines were developed partially in

response to the lessons learned from earlier attempts to implement prisonbased TCs in both Federal and State correctional systems. The guidelines

for designing programs included the following recommendations (Wexler

et al. 1991).

1. The programs were to be developed within the context of the realities

of prisons. Custody and security issues were to be carefully

considered in all planning.

2. Rehabilitation can be most effective when the efforts of both

corrections and program staff cooperate to promote prosocial

changes. This requires involving corrections staff in planning and

organizing programs; cross-training of correctional, administrative,

and program staff; and establishing and maintaining clear lines of

communication among all segments of the prison staff.

3. All prison-based programs that address substance abuse and

criminality must be consistent with the goals of all correctional staff

196
4.

5.

6.

7.

8.

by providing cost-effective ways to reduce recidivism (Wexler et al.

1988a).

All segments of the prison environment must realize that the

effectiveness of TCs in the community and in prisons has been

supported by numerous evaluation research studies.

To maximize the long-term effectiveness of in-prison treatment

program, an appropriate and complementary postrelease aftercare

program must be part of the treatment. Without aftercare, graduates

of the program who are released into the community will have less

chance to survive in the community.

Program planning must be thorough and complete. Goals,

procedures, and timetables should be established and monitored.

The outcomes for evaluation of the program must be objective and

meaningful (e.g., urine monitoring, incident reports, rearrest rates).

The program must elicit support from both the community and other

institution staff. This is achieved through extensive networking and

communication of program activities.

Training was a key element in Project REFORM. Correctional staff and

administrators at all levels participating in Project REFORM received

training in drug abuse treatment issues. Project REFORM staff prepared

trainers from many State systems to ensure continuous training within

their prison systems. Executives were given special sessions to expand

their appreciation for the role of drug abuse treatment in accomplishing

their criminal justice goals. Cross-training programs were developed for

drug abuse treatment and correctional staff to ensure that each understood

the others’ roles in the institution. National REFORM Training

Workshops, which were held biannually, offered extensive hands-on and

didactic training sessions.

Another key element was the focus on evaluation. Often, the demise of

prison drug programs was associated with both the lack of evaluation data

and questionable results from poorly designed studies. Without

documentation of a program’s effectiveness, it is difficult to obtain

continued funding of programs. Continued program support requires

regular evaluation. Therefore, each State participating in Project

REFORM was provided technical assistance to develop an in-house

197
evaluation capability. Process evaluation was encouraged during

implementation to adjust the program and ensure maximum effectiveness.

Systematic assessment of inmates’ drug histories was encouraged to

establish a database and thereby enhance the systems capability to

identify those needing treatment and determine the appropriate program

for each. Another major purpose of the program was to establish a

database for assessment of program effectiveness and client outcome.

Technical expertise was provided to assist each State in developing an

evaluation plan. Procedures for establishing and maintaining evaluation

capabilities were reviewed with participating States. In several States, for

example, an individual was designated to be responsible for evaluation.

General guidelines and standards for data collection were established.

These guidelines recommended types of variables to be included

(e.g., client characteristics, drug histories, incident reports). While each

State operated independently, all were encouraged to maintain

comparable data elements so that future comparative analyses could be

performed.

Early in the history of Project REFORM, special attention was paid to the

question of inmate classification and matching the client with treatment.

Preliminary results of those efforts suggested that incarcerated substance

abusers were less heterogeneous than originally thought, and the range of

potential drug programs was limited. However, the concept of treatment

matching remains an important one that warrants more extensive analysis

(Wexler et al. 1991).

States also were also strongly encouraged to offer programs emphasizing

the transition from prison to the community. Many inmates who

participated in the prison outpatient and residential programs were offered

prerelease transitional services, including reentry counseling and referrals

to community-based programs. In some States, prerelease programs were

followed by coordinated community-based treatment programs that

continued the process begun in the prison.

Thus far, Project REFORM has assisted 11 States (Alabama, California,

Connecticut, Delaware, Florida, Hawaii, New Jersey, New Mexico, New

York, Oregon, and Washington) in developing comprehensive plans for

prison-based drug treatment. In addition, according to Wexler and

colleagues (1991), over 400 programs have been established or improved

in response to Project REFORM initiatives, including assessment and

referral sites (134), education programs (108), drug abuse treatment

198
resource centers (46), 12-step programs (115), prerelease and postrelease

counseling programs (233), urine monitoring (146), and milieu (isolated)

in-prison programs (62). Training sites for hands-on TC experience were

established at the Stay’n Out program in New York and the Amity

program in Tucson, AZ. Project REFORM also published a newsletter

for all participating States to share ideas and experiences as well as to

keep staff and administration informed of new developments.

Summary of Current Status of TCs in Prison

Since a large number of crimes are attributable to a relatively small

number of chronic substance abusers, identification and treatment of

abusers while they are in prison should have a major impact on crime

rates. One of the major resources that Project REFORM offered was a

demonstrably effective treatment strategy, the TC approach, along with

the technical support to implement it. The Stay’n Out program, based on

the Phoenix House model that had been to be effective with prison

inmates, helped establish the foundation for these efforts.

Project RECOVERY extended and built on the work of Project

REFORM through 1992, providing support to interested States through

technical assistance, a newsletter, and semiannual National Training

Workshops.

LESSONS FROM HISTORY: IMPEDIMENTS AND

ENHANCEMENTS TO PRISON-BASED TCs

Many of the factors that affect the implementation of TCs in prison are

relevant to any prison program.

Impediments to Effective Correctional Treatment

Prison systems are, by their nature, resistant to change. The primary

function of any prison is security. Innovations that add to the risk of

escape or otherwise detract from security are seen as a threat to the

institution’s primary purpose. The perceived differences in mission

between security and program staff are often a source of frustration and

friction in performing both tasks. Inmates are also skeptical of the

purpose and motivation for new programs. They may resist from fear

that the program is a way for the administration to attack the convict

code, or in the belief that the program is another empty gesture by

199
do-gooders. Thus, it is not uncommon to find several levels of resistance

to any drug treatment program in the prison setting.

Conducting an effective drug abuse treatment program in the prison

environment is difficult. Interventions calling for openness and support

of inmates conflict with the institution’s needs for order and discipline.

Treatment staff must somehow balance and integrate security and

treatment considerations.

The resources needed for an effective TC are often burdensome to the

institution, since a dedicated unit and special treatment staff are required.

Inmates involved in such an intense program are likely to develop an

understanding of what they need and become more organized and

sophisticated consumers, placing pressure on prison resources. Inmates

not in the program see that the TC inmates get special treatment

(especially special privileges given as rewards) while they do not. This

disparity may create problems for administrators. The special groups and

other TC activities may necessitate special security arrangements. For

example, operation of a TC marathon group may require all inmates in

the group to be held on “outcount,” meaning that the activity continues

during institution counts.

The experience of the Federal and State prison systems, particularly in the

implementation of Stay’n Out and Project REFORM, shows that the

impediments to effective TCs in prison can be overcome. Important

lessons learned from the cumulative experience of the past few decades

focus on communication and training. Although a dedicated unit is

essential to a successful TC, consistent and complete orientation of TC

staff to the prison is vital. Existing prison staff must be trained about the

TC and its philosophy, mission, policies, and procedures. Staff must

maintain control over the dedicated unit in a manner that allows the

inmates appropriate levels of power without granting the inmates too

much control. Staff and inmates must have sufficient information about

the TC unit, and they must be dissuaded from accepting myths about its

operation (e.g., unusual initiation rites) and using disparaging terms to

describe it. It is important to provide adequately trained staff and

appropriate and consistent funding for the units. These programs are also

more successful if adequate aftercare programs are provided.

200
Recommendations for Effective Correctional Drug Abuse

Treatment Programs

Based on the Stay’n Out study and other research efforts (Lipton 1989;

Lipton et al. 1992; Wexler et al. 1988a), there is evidence that drug abuse

treatment in prisons can be effective. The majority of successful

community-based and prison-based programs are derived from a social

learning theory of criminal behavior (Bandura 1979; Nietzel 1979). This

theory suggests that criminal behavior is learned through a process of

social interaction. Effective treatment offers positive social interactions

and leads to the development of prosocial behavior. This can be offered

in a wide variety of programs including TCs.

The appropriate level of treatment depends on the stage of incarceration

of inmates (i.e., length of sentence already served). Some approaches,

such as drug education, are appropriate for any level of drug use or any

point in the sentence. However, inmates who have extensive lifestyle

problems and severe drug involvement need a more extensive program.

The TC is a particularly successful modality for the more serious

offenders. Inmate immersion into the TC environment provides the

intense treatment necessary to modify criminal behavior.

GUIDELINES FOR EFFECTIVE TREATMENT IN AN

IN-PRISON TC

Wexler and colleagues (1991) offered the following principles and

guidelines on the basis of their experience with Project REFORM. These

are general principles designed to guide State correctional systems in

developing an overall drug treatment program for their prison population.

From the broadest perspective, the principles Wexler and colleagues

(1991) present are intended to encourage clearly stated drug treatment

policies and better communication among agencies and sites that offer

drug treatment. The principles focus on communication among staff to

ensure support for the programs and direct all staff and inmates to the

task of reducing recidivism.

In their description of the Stay’n Out program, Wexler and Williams

(1986b) further elaborated on several features that contributed to the

success of that program. These comments may assist others who are

interested in developing new in-prison TC programs.

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1. Creation of a psychologically safe environment where inmates can

express their deepest emotions is one of the primary tasks of a TC.

Such an environment was developed for the Stay’n Out program

through a process of trial and error. For example, modifications to

decrease the harshness of group confrontation, which is typical in

community-based TCs, may require protocols for consistent and

effective implementation in the prison environment.

2. Recognize and use cultural and ethnic differences among residents.

For example, Hispanic TC members were taught to use English; other

members of the TC contributed to helping them learn English.

Cliques based on race or ethnicity were discouraged and a common

family atmosphere was promoted.

3. Emphasize program integrity. The greater the perceived integrity of

the program among the participating and nonparticipating staff and

inmates, the more likely the program is capable of providing effective

rehabilitation. Program integrity is related to the perception that the

program is strong and coherent. The program must be autonomous,

with cooperative and respectful interactions with the prison

administration and institution staff. The fact that New York

Therapeutic Communities, rather than prison staff, administered

Stay’n Out helped create program integrity. Communications with

institution staff were clear and respectful. The integrity of the

program also supported credible authority with inmates while staff

maintained positive relationships with the inmates.

4. Maintaining the respect of the inmates outside the TC program is

important to program survival. Early in the history of the Stay’n Out

TC, it became clear that the other inmates were not comfortable with

the program and harassed TC residents. To gain the respect of those

inmates, Stay’n Out residents entered sporting competitions in the

institution. After other inmates observed the teamwork and winning

style of the TC, they developed a respect for the inmates in Stay’n

out.

5. Survival of any program in the institution requires the maintenance of

discipline. As with community-based TCs, the Stay’n Out programs

have a set of cardinal rules: no drugs, sexual acting out, or theft.

Violation of these rules meant expulsion from the program. The

violations of any rules other than cardinal rules, however, were seen

as learning opportunities. Enforcement of rules must be balanced

202
with needs to maintain credibility with the security staff, maintain

discipline within the program, and focus on treatment. Stay’n Out

program rules were enforced as part of treatment. Violators who

committed infractions also were confronted by the community for

their behavior. Often the offending inmates were given a

contingency-based contract to allow them a way of working their

way into exoneration. Even inmates who were expelled were

allowed to reapply after a period of time. Thus, rule violators were

given second chances. One manifestation of the Stay’N Out

program’s success is that correctional staff generally trusted the unit

team to handle most disciplinary actions.

6. The use of ex-addicts and ex-offenders as program staff contributes

to the success of the TC. This was demonstrated by the Stay’n Out

staff, who clearly showed the personal strength and integrity of those

who have successfully completed treatment themselves. These

people are deeply committed and have the faith in the program

necessary to inspire TC clients and maintain the respect of inmates

and staff.

7. Some form of continuity of care must be offered to inmates. This

requires the program staff to develop ties with community-based

programs. The exact nature of the program (general supervision,

self-help groups, or half-way house) depends on the inmates’ specific

needs and available community resources. For many offenders,

prison-based treatment should be followed by treatment in the

community.

8. Program evaluation should be a part of the program planning and

continue throughout the life of the program. An effective evaluation

informs staff about the implementation as well as effectiveness of the

TC.

CONCLUSION: THE FUTURE OF TCs IN CORRECTIONS

The prison-based TC has become widely accepted as the treatment of

choice for inmates with severe substance abuse histories. Through the

efforts of States that participated in Projects REFORM and RECOVERY,

a number of excellent programs have been established. As TCs are

accepted as an effective way to reduce recidivism rates, more States are

becoming interested in developing prison programs. Recently, Texas

203
passed a billion dollar bond package that provides for 25,000 new prison

beds, including 12,000 dedicated to substance abuse treatment. The

primary prison treatment modality being considered in the Texas system

is the TC. As more prison TCs are established, the following issues

require consideration.

1.

2.

3.

4.

5.

6.

Maintenance of program quality is difficult when many TCs have to

be established in a short timeframe. Good TCs take at least a year to

build up their treatment culture and establish a core of experienced

staff and residents who can deliver a quality program.

Staff recruitment and selection are pressing issues. There is a finite

number of trained recovering people who can serve as credible role

models, having demonstrated several years of productive drug-free

living. Many established community and prison TCs are concerned

that they may lose their more experienced staff. A central

employment service needs to be established to recruit and select staff

and publicize job opportunities.

Training is one of the most critical problems in the field. Although

Projects REFORM and RECOVERY have conducted a number of

training events, and training facilities have been established at the

Stay’n Out program in New York and Amity program in Tucson,

training efforts must be expanded to meet the rising need.

The issues of program accreditation and counselor certification need

to be fully explored. As the field expands, participants need to be

professionalized and career paths need to be established. Care needs

to be taken to include and use the vitality and experience of

recovering people in this process.

The relationship between community and prison TCs needs to be

strengthened. Many community TCs express some resistance to

accepting parolees or giving them advanced status when they have

prison TC experience. Prisons that are interested in developing TC

treatment programs can receive invaluable assistance if they form

relationships with local community TCs.

A continuous care model must be established. Major obstacles that

face inmates upon release are inadequate education and vocational

experience and a scarcity of jobs and housing. Too often,

rehabilitated parolees return to their old neighborhoods, cannot find

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work, become frustrated, and return to criminal lifestyles. The Stay’n

Out program in New York and Amity-Righturn program in San

Diego have established community facilities to assist prison TC

graduates returning to the community. Linkages between agencies in

the education, health, employment, and housing areas must be

strengthened to support the recovery process in the community.

7. Although research has established the efficacy of prison TCs,

systematic studies are needed to explore variations in the TC model,

identify for whom the TC is most effective, clarify the role of

recovering staff, document the effects of the program on host

institutions, and establish the cost-effectiveness of TCs.

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207
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ACKNOWLEDGMENTS

The content of this chapter greatly benefited from the efforts of other

researchers, including Doug Lipton, Ph.D., Bruce Johnson, Ph.D.,

Gregory Falkin, Ph.D., and Ron Williams.

AUTHORS

Harry K. Wexler, Ph.D.

Principal Investigator

Center for Therapeutic Community Research

National Development and Research Institutes

380 Glenneyre, Suite D

Laguna Beach, CA 92651

Craig T. Love

Director of Research and Evaluation

Spectrum Addiction Services, Inc.

106 East Main Street

Westboro, MA 01581

208
Co-Morbidity and Therapeutic

Community Treatment

Nancy Jainchill

INTRODUCTION

Three facts have been critical to the growing concern and increasing

knowledge about substance abusers in general and about their

psychological characteristics in particular. First, there has been the

recognition that treatment does not work for everyone and that informed

policies might enhance treatment effectiveness. Second, the enculturation

of drug use has brought a widening spectrum of people into treatment

with a diversity of problems in addition to their drug use. Widespread

drug use, earlier age of onset, and the greater variety of drugs used are

associated with psychiatric, psychosocial, developmental, and physical

problems (Friedman and Beschner 1985). Third, the development of

improved research tools has made possible the investigation of

psychiatric and psychological issues. The relatively recent formulation of

an improved nosological system to classify disorders provided by the

Diagnostic and Statistical Manual of Mental Disorders (DSM-III,

DSM-III-R) (American Psychiatric Association 1980, 1987) and the

development of structured interviews to render diagnoses have enhanced

the possibilities of more accurately and usefully distinguishing drug

abusers who seek treatment along psychiatric dimensions.

Chein and colleagues (1964) suggested a characterization of the teenage

addict that has applicability to drug users in general. They described a

continuum that puts the multidimensionality of the addict into perspective

and defines issues that are relevant to current attempts to understand the

psychology of the drug abuser.

The addiction of the [adolescents] . . . studied was an

extension of or a development out of, long-lasting

severe, personality disturbance and maladjustment.

The addiction of the adolescents we have studied was

adaptive, functional, and dynamic (Chein et al. 1964,

p. 194).

209
Thus, two facets of addiction were recognized: one reflecting a

pathological condition, the second an adaptive response to environmental

conditions.

The changing trends in drug abuse patterns and in drug users seeking

treatment have emphasized the importance of considering psychological

and psychiatric factors in the treatment of substance abuse. Specific

psychiatric disorders such as depression, antisocial personality, and

borderline personality disorder appear to occur more frequently among

drug users (Meyer 1986), although the question of sequence (i.e., cause)

remains unanswered. Some recent investigative efforts have focused on

clarifying the complex relationship between addictive conditions and

psychopathology.

This chapter provides an overview of the research that has been

completed as well as a discussion of the issues related to future research

and treatment. Studies that reported on the psychological characteristics

of substance abusers in treatment are reviewed in the first section. The

second section presents a review of studies that utilized psychiatric

assessments. In the final section, a discussion of the implications for

treatment and research is offered.

DEFINITIONS

Psychological and psychopathological symptoms refer to conditions that

are generally more transient than those described by psychiatric

diagnostic classifications, and the symptoms may be situationally

induced. Psychiatric disorders are defined according to the system of

classification detailed in the DSM-III and DSM-III-R (American

Psychiatric Association 1980, 1987). Each mental disorder is

conceptualized as a clinically significant behavioral or psychological

syndrome that is typically associated with either a painful symptom

(distress) or impairment in functioning. This system provides a uniform

convention for identifying and diagnosing symptomatology, which has

important implications for treatment and research, as discussed later.

Substance use disorders are distinguished from other psychiatric

disorders. The research described below (De Leon 1988a ; Jainchill 1989)

utilized DSM-III classifications, which differentiated between substance

abuse and substance dependence. In the revised DSM-III (DSM-III-R),

this distinction is eliminated because of “problems using social and

210
occupational consequences to define abuse, inadequacy of tolerance or

withdrawal as a required criterion for dependence, and inconsistencies in

the relationship of abuse to dependence for various substances . . .”

(American Psychiatric Association 1987, p. 417).

PSYCHOLOGICAL PROFILES OF ADMISSIONS TO

THERAPEUTIC COMMUNITIES

Instrumentation

The most frequently used measures have been the Minnesota Multiphasic

Personality Inventory (MMPI), the Tennessee Self Concept Scales

(TSCS) (Fitts 1965; Roid and Fitts 1991); the Beck Depression Inventory

(BDI) (Beck 1979; Beck et al. 1961); the Shortened Manifest Anxiety

Scale (SMAS) (Bendig 1956); the Shortened Schizophrenia Scale (SSS)

(Clark and Danielson 1956); and the Symptom Checklist (SCL-90)

(Derogatis 1983). These instruments have been standardized and their

reliability and validity are established. They are self-administered

measures that can be given individually as well as to groups.

Overview of Main Findings

The earliest studies investigating the psychological characteristics of drug

users in treatment have reported data obtained from narcotic addicts and

all-male samples, usually not from therapeutic community (TC) settings.

Research involving TCs began in the early 1970s (De Leon et al. 1973)

with a study that obtained measures of psychopathology in a crosssectional sample of clients in a large urban TC. Scores were most deviant

for residents tested during the early days of treatment.

Findings from other studies (De Leon 1974, 1984, 1988a , 1988b;

De Leon and Jainchill 1981; Holland 1986) reveal that admissions to TCs

yield high levels of depression and anxiety, poor socialization, and IQs in

the dull-normal range. MMPI profiles generally are deviant. The

prominent peaks indicate character disorder (Pd) and an elevated

schizophrenia (SC) scale, suggesting disturbed thinking and affect (see

figures 1A, 1B). Self-esteem also is very low as indicated by the

depressed TSCS profile, which also contains elements of emotional

instability and delinquent profiles.

211
FIGURE 1A. The MMPI profile of 1974 male admissions to TC treatment

KEY: L = lie scale; F = validity scale; K = correction scale; Hs = hypochondriasis; D = depression;

Hy = hysteria; Pd = psychopathic deviate; Mf = masculinity-femininity; Pa = paranoia;

Pt = psychasthenia; Sc = schizophrenia; Ma = hypomania; Si = social introversion
FIGURE 1B. The MMPI profile of 1974 female admissions to TC treatment

KEY: L = lie scale; F = validity scale; K = correction scale; Hs = hypochondriasis; D = depression;

Hy = hysteria; Pd = psychopathic deviate; Mf = masculinity-femininity; Pa = paranoia;

Pt = psychasthenia; Sc = schizophrenia; Ma = hypomania; Si = social introversion
Scores on the nine symptom dimensions of the SCL-90 (somatization,

obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety,

hostility, phobia, paranoia, psychosis, and a global severity index) are

significantly above normal, and the profile is similar to that of a

comparison group of psychiatric outpatients. For the same sample,

responses to a structured interview reveal that 38 percent had experienced

a serious depression, 27 percent had had at least one anxiety attack, and

28 percent stated a previous suicide attempt (Holland 1986).

Demography and Primary Drug of Abuse. Females generally show

poorer scores on measures of self-esteem and psychopathological

symptoms (e.g., depression, anxiety, schizophrenic signs). However, the

more stable dimensions of personality reflected on the MMPI show

relatively few differences between male and female profiles. Whites and

nonopioid abusers also generally reveal poorer psychological profiles,

although this is probably due to an interaction between ethnicity and

primary drug of abuse.

Trends

Recent research points to an increased prevalence of psychopathology

among substance abusers in general (De Leon 1988a; Jainchill and

De Leon 1992). This corroborates the clinical impression in TCs that

among current admissions, psychological problems are worse than in

earlier cohorts.

Comparisons among three entry cohorts (1974, 1979, 1984) are

summarized below. The 1974 and 1984 samples are drawn from a single,

large, urban TC. The 1979 sample was developed from admissions to a

consortium of seven TC programs that were diverse in size and period of

existence. Table 1 shows the demographic and drug of abuse profiles for

the three cohorts. The 1984 cohort reveals poorer scores than either of

the two earlier cohorts on psychopathological symptoms, particularly

depression (see tables 2A, 2B). Similarly, although the shape of the

profiles of the TSCS is virtually identical for the three cohorts, the

statistically significant differences obtained generally indicate poorer

scores for the more recent 1984 cohort.

Of particular note is that when controlled for gender, this trend is

apparent for males but not for females. That is, across the 10-year study

period, males entering treatment reveal increasing disturbance in terms of

214
TABLE 1. Demographic and primary drug of abuse characteristics of

admissions to the 1974, 1979, and 1984 cohorts

Sex

Male

Female

Total

Ethnicity

Black

Hispanic

White

Others

Total

Age

< 19

19-26

27+

Total

Primary Drug

Marijuana 113 26.4 132 14.1 165 15.8

Cocaine 18 4.2 62 6.6 445 42.7

Opiates 166 38.8 320 34.2 283 27.1

Alcohol 108 25.2 85 9.1 57 5.5

Others 23 5.4 336 35.9 93 8.9

Total 428 100.0 935 100.0 1043 100.0

Phoenix House

1974 Cohort

N %

444 83.5 762 77.9 828 78.5

88 16.5 216 22.1 227 21.5

532 100.0 978 100.0 1055 100.0

322 60.5 338 35.0 544 51.6

90 16.9 60 6.2 278 26.4

117 22.0 557 57.7 226 21.4

3 0.6 11 1.1 7 0.7

532 100.0 966 100.0 1055 100.0

94 18.6 206 21.3 233 22.1

248 49.1 466 48.2 440 41.8

163 32.3 294 30.4 380 36.1

505 100.0 966 100.0 1053 100.0

Consortium

1979 Cohort

N %

Phoenix House

1984 Cohort

N %

NOTE: A polydrug group was excluded from comparison since this

category was defined only in the 1974 cohort. However, the

majority of clients in all cohorts were multiple drug users.

215
TABLE 2A. Means and standard deviations (SD) on four measures of

psychopathology and beta IQ for three cohorts: 1974,

1979, and 1984

Scale Mean Mean S D

Beck

Depression

Anxiety

Schizophrenia

Socialization+

16.3

9.5

7.2

26.1 — —

Beta IQ 91.2

1974

(N = 492)

SD

9.5

4.5

4.1

5.5

14.7

1979 1984

(N = 736) ( N = 949)

Mean S D

16.0 9.2

10.0 5.0

7.8 4.3

(N = 657)

86.7 13.8

19.6 8.7

10.3 4.6

7.9 4.1

25.9 5.4

(N = 899)

82.9 13.1

KEY: + The Socialization Scale was not obtained on admissions to the

seven programs of the 1979 Therapeutic Communities of America

Consortium.

lower self-esteem and worsening symptom scores. However, females

show little change, so that males and females entering treatment look

increasingly similar psychologically (figure 2).

Improvement in Treatment

A number of studies report that psychological improvement is shown by

clients who are reexamined during treatment (De Leon 1984, 1988b;

Holland 1986; Zuckerman et al. 1975). MMPI profiles improve,

specifically depressive and neurotic symptoms and the ego strength scale.

Levels of self-esteem also show significant positive change, as do the

SCL-90 scales measuring neurotic and psychotic dimensions (but not

psychopathy).

216
TABLE 2B. Summary of significant differences between cohorts on four

measures of psychopathology and beta IQ: 1974, 1979,

and 1984

1974

vs. 1984

Scale

Beck

Depression

Anxiety

t-test

6.43***

2.97**

Schizophrenia

Socialization

Beta IQ

3.46***

-0.61

-10.64***

Group Comparisons+

1974

vs. 1979

t-test

0.54 -8.25***

1.89 -1.18

0.68 0.68

-5.23*** 5.52***

1979

vs. 1984

t-test

KEY: + The t-test for independent samples was used to assess group

differences; *** p < .001; ** p < .01.

Retention and Outcome: Psychology as Criterion and

Predictor

Psychological Status as Predictor. Initial psychological scores are not

reliable predictors of retention or posttreatment outcome (De Leon 1984).

Evidence suggests an indirect relationship between psychological

disturbance and long-term outcomes, mediated through retention. Early

studies by some investigators (De Leon et al. 1973; Sacks and Levy

1979; Zuckerman et al. 1975) reported that clients who left treatment

against clinical advice had poorer scores at initial testing. That is, longer

time in program is related to better psychological status at admission and

also is predictive of later improvement.

The findings that relate psychological status to posttreatment outcome are

inconsistent (De Leon 1984; De Leon and Jainchill 1981; McLellan et al.

1983, 1986). De Leon (1984), in contrast to McLellan and colleagues

(1983, 1984), found virtually no differences between the admissions

217
FIGURE 2. The scores on five psychological scales are shown

by gender for four different admissions cohorts to

TC treatment. For females, the scores show little or

no change across the 12-year period. However,

male admissions show increasingly worse scores.

There are virtually no gender differences in scores

by 1986.

218
psychological profiles of those who left treatment prematurely (dropouts)

and those who completed treatment (graduates).

McLellan and colleagues (1983, 1986) found that greater pretreatment

psychological disturbance was related to poorer followup status. In

another study that investigated the relationship between psychological

status, retention, and improvement, McLellan and coworkers (1984) also

reported an interaction between time in program, psychological status,

and improvement. Those with greater psychopathology at admission to a

TC showed a worsening at 6 months followup, compared with those who

were least disturbed and required minimal time in treatment. The

strongest correlation between treatment duration and outcome was seen in

the midseverity group.

However, the findings from these three studies must be interpreted with

caution since the TCs were hospital-based, short-term programs (usually

90 days) and would not be considered by many to be true TCs.

Furthermore, 90 days is a very short treatment episode in which to “cure”

seriously disturbed individuals, whether in a TC or otherwise.

Psychological Status as Criterion. In the aforementioned study

(De Leon 1984), both dropouts and graduates showed significant

psychological improvement, although greater positive change was seen

among individuals with longer time in treatment. De Leon also reported

a positive relationship among other (nonpsychological) outcome

measures, posttreatment psychological status, and retention in treatment.

A success index was derived by assessing clients’ posttreatment social

adjustment on the dimensions of drug use, criminal behavior, and

employment (De Leon 1984; De Leon et al. 1982). Individuals who were

evaluated as unsuccessful at followup also showed no positive changes

on psychological dimensions. In contrast, those revealing favorable

social adjustment also showed significant psychological improvement at

followup. Posttreatment psychological improvement, beyond positive

changes obtained during treatment, was greater for females (De Leon

1984; De Leon and Jainchill 1981).

In summary, individuals who enter TCs show a marked degree of

psychopathology, as indicated by deviant scores on measures of

depression and anxiety and on the symptom dimensions of the SCL-90.

Their self-esteem is low, and the pattern of the profiles resembles that of

psychiatric and criminal populations. Psychological profiles appear to be

worsening across the 10-year period from 1974 to 1984, particularly for

219
males. The findings vary concerning the relationship between

psychological status at admission and posttreatment outcome, and at best

suggest a weak association.

Psychological status at followup is related to retention and to other

posttreatment behavioral measures. Longer time in treatment is

correlated with greater psychological change at followup, which also is

associated with more positive outcomes on behavioral measures (e.g., no

drug use, no criminality, employment). Females show greater

improvement, particularly beyond in-treatment change.

CO-MORBIDITY AMONG ADMISSIONS TO TCs

The objective of many studies during the past 10 years has been to

classify substance abusers according to established psychiatric criteria.

This has become possible because of the development of a nosological

system to classify disturbances descriptively and the development of

structured instruments to obtain the diagnoses. The most frequently used

systems have been the Research Diagnostic Criteria (RDC) (Spitzer et al.

1975) and the DSM-III and -III-R (American Psychiatric Association

1980, 1987). The DSM-III is derived from the RDC, and the two

systems are highly comparable (Rounsaville et al. 1980). The more

commonly used instruments are the Schedule for Affective Disorders and

Schizophrenia (SADS) (Spitzer and Endicott 1978-79) and the Diagnostic

Interview Schedule (DIS) (Robins and Helzer 1985; Robins et al. 1988).

There have been almost no studies of the prevalence of psychiatric

disorders among admissions to TCs. Most researchers have used the

SADS on non-TC samples: a uniform finding has been that the majority

of addicts seeking treatment received diagnoses other than substance

abuse. Generally, there is a high incidence of affective disorders and

antisocial personality (Rounsaville et al. 1985). One investigative team

that utilized the DIS found that for alcohol abusers, a psychiatric disorder

more often preceded alcohol abuse, while the reverse was true among

drug abusers (Ross et al. 1988). The findings of a study that describes the

incidence of psychiatric disorders among admissions to a large, urban TC

(De Leon 1988a; Jainchill 1989) are described below.

Sample. The data were gathered on more than 350 admissions to

treatment across a 3-year period (1985-87). The majority of the sample

were male and black, with cocaine identified as the primary drug. There

220
was a disproportionate sampling of women to ensure a sufficient number

for analyses; thus, 44 percent of the study cohort was female compared to

30 percent of the treatment population from which it was drawn.

Additionally, the sample was older than the residential population, since

the DIS is recommended for use with individuals at least 18 years of age.

Therefore, all residential admittees under age 18 were excluded from the

study.

Instrumentation. The DIS is a structured interview that can be

administered by specially trained lay interviewers. The presence of

symptoms is coded and nonpsychiatric causes, such as medical illness or

drug/alcohol use, are distinguished from psychiatric attributions. A

historical summary of psychiatric disturbance is obtained, in which age of

onset and age of most recent occurrence are ascertained for each positive

diagnosis. The DIS is structured so that diagnoses are computer

generated. (For a more detailed description of the DIS, see Jainchill

1989.)

Admissions Profiles. Table 3 shows the incidence of psychiatric

diagnoses obtained during the client’s lifetime (ever) and during the

month prior to interview (current). Eighty-two percent of the sample had

a psychiatric (nondrug/alcohol) lifetime diagnosis, and more than 45

percent of the sample had a psychiatric disorder in the month prior to

entering treatment. There were no significant differences among

demographic and primary drug of abuse groups.

The distribution of separate lifetime DSM-III disorders is shown in table

4. The most commonly occurring nonsubstance diagnoses are in order of

frequency: antisocial personality, psychosexual dysfunction, generalized

anxiety, phobias, dysthymia, and major depression.

Demography and Primary Drug of Abuse. There were a number of

gender differences in diagnoses. Proportionately more females had major

depressive disorder, phobic disorders, and psychosexual dysfunction,

while more males were diagnosed with antisocial personality. There were

no ethnic differences on any of the psychiatric disorders. Among the

primary drug groups, heroin abusers had a higher incidence of phobic

disorders.

The distribution of substance use disorders reflected the self-reported

primary drug groupings. The most frequently obtained diagnosis was

cocaine abuse (79 percent), which was the most commonly reported

221
TABLE 3. Current and lifetime diagnoses: Substance only, psychiatric

only, and substance plus psychiatric

Lifetime Current

Diagnoses Diagnoses

Number Percent Number Percent

Any diagnosis 349 97.21 286 79.67

Substance only 53 14.76 121 33.70

Psychiatric only 15 4.18 44 12.26

Substance plus

psychiatric

281 78.27 121 33.70

KEY: N = 359

primary drug of abuse by the sample. However, the percentage with a

cocaine abuse disorder exceeded the proportion who stated cocaine as

their primary drug (79 percent versus 64 percent), indicating that some

proportion of individuals had heavy cocaine use, although they did not

consider it to be their main drug. This corroborates the finding that the

majority of the sample were frequent users of more than one drug. Males

and nonblacks revealed a significantly higher incidence of use of drugs

other than cocaine. Clients who stated cocaine as their primary drug of

use revealed a generally lower incidence of other drug use.

Psychiatric Status, Retention, and Progress in Treatment. Two

groups, those who remained in treatment at least 3 months and those who

dropped out prior to 3 months, were identified. The demographic and

primary drug distributions were not different for the two groups, nor were

there any differences in the distribution of the separate psychiatric

disorders. The groups differed only with respect to the substance

disorders: those in treatment less than 3 months had a higher percentage

with a marijuana disorder, and more members of this group obtained

combined abuse/dependence diagnoses.

Six variables that delineate dimensions of disturbance across all of the

psychiatric disorders were computed. (For more information concerning

methodology, see Jainchill 1989.) Those in the group with longer

retention had higher (more severe) values for “number of psychiatric

222
TABLE 4. Distribution of DSM-III diagnoses among admissions to

residential drug treatment

Diagnosis Number Percent

Organic brain syndrome

Definitely mild 9 2.51

Could be severe, mild, or absent 5 1.39

Affective disorders

Manic episode 7 1.96

Major depression 43 12.32

Dysthymia 59 16.91

Bipolar disorder 1 0.28

Atypical bipolar disorder 8 2.29

Schizophrenic disorders

Schizophrenia 9 2.51

Schizophreniform 0 0.00

Anxiety disorders

Obsessive compulsive disorder 19 5.32

Phobic disorders 99 27.73

Agoraphobia 57 15.97

Simple phobia 55 15.41

Social phobia 38 10.64

Panic disorder 9 2.51

Generalized anxiety 107 34.19

Other

Antisocial personality 156 44.07

Somatization disorder 0 0.00

Anorexia 0 0.00

Pathological gambling 22 6.20

Psychosexual dysfunction 141 39.83

Bulimia 1 0.31

Posttraumatic stress 25 10.59

Ego dystonic homosexuality 5 2.14

Transsexualism 1 0.77

223
TABLE 4. Distribution of DSM-III diagnoses among admissions to

residential drug treatment (continued)

Diagnosis Number Percent

Substance abuse/

dependence disorders

Alcohol 141 39.28

Abuse 45 12.53

Dependence 13 3.62

Abuse + dependence 83 23.12

Barbiturates 51 14.21

Abuse 4 1.11

Dependence 22 6.13

Abuse + dependence 25 6.96

Opioids (heroin) 98 27.30

Abuse 3 0.84

Dependence 20 5.57

Abuse + dependence 75 20.89

Cocaine abuse 284 79.1 1

Amphetamines 36 10.03

Abuse 6 1.67

Dependence 16 4.46

Abuse + dependence 14 3.90

Hallucinogen abuse 32 8.91

Marijuana 143 39.83

Abuse 57 15.88

Dependence 34 9.47

Abuse + dependence 52 14.48

KEY: N = 349 to 359 for all but the following diagnoses:

generalized anxiety, N = 313; bulimia, N = 320; posttraumatic

stress, N = 236; ego dystonic homosexuality, N = 234;

transsexualism, N = 130

NOTE: Cocaine and hallucinogens: DSM-III has no dependence

diagnosis.

224
symptoms” and “number of lifetime diagnoses.” A discriminant

analysis was performed to assess whether the two groups could be

further differentiated along psychiatric dimensions. A greater

incidence of “lifetime diagnoses” and a higher score on “adult

antisocial personality” (a factor reflecting antisocial personality

symptoms with an adult onset) were positively associated with

retention. Psychiatric disturbance alone, without an accompanying

drug disorder, was negatively associated with retention. Thus, clients

with longer retention tend to have more history of psychiatric disorder

in addition to their substance abuse; however, psychiatric disturbance

alone is negatively associated with retention.

A progress score was derived for individuals who remained in

treatment at least 3 months. The score was based on a 90-day

summary and monthly evaluations, both completed by clinical staff.

A regression analysis was performed to assess the relationship

between client progress and adjustment to treatment and psychiatric

status at admission. A high (favorable) progress score was associated

with being black and manifesting less psychiatric disturbance at

admission. “Childhood antisocial personality” (a factor reflecting

symptoms with onset before age 15) was negatively associated with

progress. Thus, clients whose deviant behavior begins early seem to

have more trouble adjusting to treatment. This finding is discussed

further in the following section.

IMPLICATIONS FOR TREATMENT AND RESEARCH

Substance abusers show features from both psychiatric and criminal

populations. The profiles of treatment admissions appear to have

worsened over a 10-year period, and the large majority (78 percent)

are dually diagnosed (substance plus psychiatric disorders), although

frank psychosis is the exception (De Leon 1988a, 1988b; Jainchill

1989; Jainchill and De Leon 1992).

In the literature on psychopathology and psychiatric disorders among

substance abusers in settings other than the TC, the results generally

are similar. There is some difference in the prevalence rates obtained

from the TC sample reported above, compared with those shown by

other investigators. In particular, Rounsaville and colleagues (1985)

reported a lifetime incidence of major depression that was four times

225
the incidence shown in the aforementioned study, but the frequency of

antisocial personality disorder was half that obtained (De Leon 1988a;

Jainchill 1989).

However, other investigators (Ross et al. 1988) have shown very

similar distributions to those obtained in the TC study. For example,

Ross and colleagues reported that an almost identical percentage of

clients yielded a lifetime psychiatric diagnosis, and the distribution of

the specific disorders generally was comparable. Some of the

variance in findings may be attributable to differences in the

instruments that were used: Rounsaville and colleagues (1985) used

the SADS, while Ross and coworkers (1988) used the DIS.

To further clarify the role of psychiatric symptomatology in drug

abuse, investigators have attempted to delineate the symptom picture

of specific disorders. For example, Rounsaville and colleagues (1985)

described the profile of depression among opiate addicts. They found

that most addicts reported having had a single episode that succeeded

drug abuse, and there was a relatively infrequent occurrence of

psychotic symptomatology and incapacitating symptom levels. In

contrast, the depressive episodes of psychiatric populations yield a far

more severe symptom picture.

Investigators, including Rounsaville and coworkers (1985), also have

attempted to derive a typology of substance abusers along psychiatric

dimensions. For example, three major subtypes of cocaine abusers

have been hypothesized, with recommendations for different treatment

strategies for each type (Weiss et al. 1986). These findings, although

preliminary, highlight salient issues that should be addressed in future

studies to clarify and improve the treatment and recovery process.

The following points provide a focus for this work.

1. The identification of psychiatric subtypes. Aside from the

aforementioned efforts to define subgroups of cocaine abusers,

more general typologies are suggested. For example, individuals

can be classified according to (1) those who are primarily drug

abusers, with accompanying psychopathology; (2) those whose

primary symptomatology is psychiatric, with accompanying drug

abuse; (3) those for whom substance abuse and psychiatric

disorders are equally present and interactive; and (4) those with a

substance abuse disorder without psychiatric symptomatology.

Distinguishing among these types is difficult, since the

226
relationship is obvious only with the most extreme examples in

each group.

2. The temporal relationship between substance abuse and

other psychiatric disorders, in terms of onset or sequence,

needs to be examined. This includes elucidating the

association among temporal order, psychiatric type, and symptom

picture (i.e., does depression that precedes drug use present

differently from episodes that succeed or are coincident with the

drug problem?).

3. The role of antisocial personality in the recovery process, in

particular the differentiation of childhood and adult features,

requires clarification. Jainchill (l989) factor analyzed the

symptom-items from the DIS for antisocial personality, and they

subdivided into one factor characterized by childhood symptoms

and a second factor identified by adult behaviors. There was a

small negative relationship between the childhood factor and

3 months of retention, and this factor was negatively associated

with progress in treatment. In contrast, the adult factor was

positively associated with remaining in treatment for at least

3 months. However, the disorder, as obtained with the DIS, was

not associated with either retention or progress. This finding

suggests that the conventional DSM-III and -III-R criteria used to

diagnose antisocial personality disorder may be inadequate.

The diagnostic utility of distinguishing among individuals with

antisocial personality disorder, those who manifest a minimal

number of childhood symptoms from those who have a large

number of childhood symptoms, should be considered. An early

onset of more deviant behaviors (childhood features) may be

indicative of greater psychopathology, with implications for

prognosis and treatment. For example, in the aforementioned

study, clients with more childhood symptoms were less likely to

remain in treatment, and those who did stay at least 3 months had

more trouble adjusting. The latter fact could be associated with

poorer long-term retention rates and remains an issue for future

study.

4. The impact of subcultural conditions on psychological

disease and behavior must be clarified, The degree of

psychopathology manifested may be inversely related to how

227
much social pressure against addiction there is within the

individual’s social milieu. Two apparently identical diagnoses

may reflect different syndromes, and, though criteria for a

disorder may be met, it is important that the adaptive response be

distinguished from the pathological condition. This issue has

particular relevance for people of color and for women.

TCs are acknowledging the complexity of the problem of drug use.

The TC model is being adapted to address the multivariate needs of

drug-abusing clients who seek treatment. Staff members of most

programs reflect an integration of traditional recovered counselors and

individuals trained as mental health professionals. Further

modifications to treatment procedures may involve special staff

training, changes in recommended lengths of stay, the use of modified

encounter groups, and the application of methods and concepts from

the mental health system. Changes in structure and staffing may be

needed to accommodate those clients who are admitted now, and

perhaps to offer access to those who have been turned away in the

past. Historically, TCs have been successful in working with

individuals whose primary problem is drug abuse. The challenge is to

adapt the model and methodology to meet the expanding needs of

those seeking treatment, while retaining the self-help perspective and

community dynamic.

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McLellan, A.T.; Childress, A.R.; Griffith, J.; and Woody, G.E. The

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1984.

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Druley, K.A. Increased effectiveness of substance abuse treatment.

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Robins, L.N., and Helzer, J.E. Diagnostic Interview Schedule (DIS),

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psychiatric disorders in patients with alcohol and other drug

problems. Arch Gen Psychiatry 45:1023-1031, 1988.

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Evaluating and Treating Depressive Disorders in Opiate Addicts.

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U.S. Govt. Print. Off., 1985.

Rounsaville, B.J.; Rosenberger, P.; Wilber, C.; Weissman, M.M.; and

Kleber, H.D. A comparison of the SADS/RDC and the DSM-III:

Diagnosing drug abusers. J Nerv Ment Dis 168(2):90-97, 1980.

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1979.

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Weiss, R.D.; Mirin, S.M.; and Michael, J.L. Psychopathology in

chronic cocaine abusers. Am J Drug Alcohol Abuse 12(1/2):17-29,

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AUTHOR

Nancy Jainchill, Ph.D.

Senior Principal Investigator

Center for Therapeutic Community Research

National Development and Research Institutes

11 Beach Street

New York, NY 10013

231
HIV and Therapeutic Communities

Jane McCusker and James L. Sorensen

INTRODUCTION

The epidemic of disease related to the human immunodeficiency virus

type 1 (HIV-1, henceforth referred to as HIV) presents urgent challenges

for therapeutic communities (TCs); however, TCs have great potential to

slow the spread of HIV disease if they can negotiate these challenges

successfully. Prevention and control of HIV infection in drug users

involve multiple strategies, including enhanced entry into and retention in

effective treatment programs for drug abuse, group education, individual

counseling, voluntary HIV antibody testing, and medical treatment and

other services for HIV-infected drug users.

After a discussion of the natural history and epidemiology of HIV disease

in drug users, this chapter will focus on strategies in the control of the

HIV epidemic that are relevant to TCs. These strategies are organized

under the headings of primary, secondary, and tertiary prevention (figure

1). Primary prevention strategies are those that reduce HIV transmission.

Secondary prevention strategies include early detection and prompt

treatment of early HIV disease, and tertiary prevention strategies aim to

reduce morbidity and mortality among persons with late-stage disease.

Finally, the chapter will review the published literature in each of these

areas and highlight research needs.

Epidemiology

Knowledge has developed rapidly regarding the epidemiology, methods

of transmission, and natural history of HIV infection (Mathews et al.

1990). HIV infection and acquired immunodeficiency syndrome (AIDS)

are phases of a chronic disease, referred to as HIV disease. A diagnosis

of AIDS is made on the basis of indicator conditions, including

opportunistic infections and neoplasms. The revision of the AIDS case

definition to include persons with a CD4+ T-cell count of less than

200/μL will increase the number of HIV-infected persons meeting the

AIDS case definition (Centers for Disease Control 1993). This new

definition will lead to an estimated 50-percent increase in the number of

persons recognized as living with AIDS and perhaps a much greater

increase among injection drug users (IDUs) (Des Jarlais et al. 1992).

232
Primary Prevention

Access to drug treatment of high-risk drug users

Retention in drug treatment of high-risk drug users

HIV education and counseling

Secondary Prevention

HIV antibody testing

Contact notification

Early medical treatment

Coordination with community services

Tertiary Prevention

Medical treatment of advanced disease

Palliative and terminal care

Coordination with community services

FIGURE 1. Levels of prevention of HIV disease among drug users

However, populations with poorer access to care, including drug users,

may be less likely to be identified as having AIDS than populations with

better access (Chang et al. 1992).

During the early period of disease, HIV-infected persons mainly are

asymptomatic. The median incubation period between initial infection

and development of AIDS is estimated to be at least 8 to 10 years.

Treatments that lengthen the incubation period will significantly affect

the need for care and medical surveillance of persons with HIV disease.

Survival after a diagnosis of AIDS usually is short, particularly among

IDUs (Harris 1990).

A diagnosis of AIDS, while essential for epidemiological surveillance, is

of limited use for management and intervention programs, as it excludes a

substantial amount of severe HIV disease. It is particularly inadequate

when applied to drug users, who have been shown to experience a

substantial HIV-related excess morbidity and mortality not included in

the current AIDS case definition (Mientjes et al. 1992; Stoneburner et al.

233
1988). Therefore, it is more appropriate to refer to different stages in the

natural history of HIV disease as early or advanced HIV disease.

Substance users are recognized to be at high risk of HIV disease,

primarily through drug injection with nonsterile injection equipment but

also through risky sexual practices that tend to be associated with drug

and alcohol use (Minkoff et al. 1990; Rolfs et al. 1990; Schoenbaum et al.

1989; Sterk 1988). Some investigators have found the prevalence of

these risky behaviors to be lower in drug users entering treatment than

among nondrug treatment samples (Lampinen et al. 1992; McCusker et

al. 1990, 1992a). However, a substantial percentage of those entering

treatment report drug injection or sexual behaviors that place them and

their needle sharing and sexual partners at risk.

Incidence and prevalence rates of HIV and AIDS reflect not only the

above risk behaviors but also the prevalence of HIV in the social

networks within which drug users share injection equipment and make

sexual contacts. Thus, the prevalence of HIV among IDUs entering

treatment varies widely by geographic area, with higher prevalence rates

found in populations closer to the HIV epicenters of New York and New

Jersey (Hahn et al. 1989; Lange et al. 1988). Other variables associated

with an increased HIV risk include race or ethnicity (Chaisson et al.

1987; Koblin et al. 1990; Schoenbaum et al. 1989; Williams 1990). Use

of cocaine, particularly “crack” cocaine, also has been found to be

associated with increased HIV risk, presumably due to the association of

cocaine use with riskier sexual practices (Chiasson et al. 1991).

PRIMARY PREVENTION

TCs can effect primary prevention by admitting high-risk drug abusers

into treatment and by retaining those clients long enough to treat the

primary drug abuse problem effectively. Thus, the treatment program

itself reduces HIV transmission through increasing abstinence from

high-risk drug use. For those clients who do not complete the program

successfully or who relapse after completion, TCs can prepare them for

safer relapse through specific educational and other interventions (Baker

et al. 1993).

Sexual risk reduction must be emphasized in addition to reduction of the

risks associated with drug use (Schoenbaum et al. 1989). A number of

studies have suggested that sexual risk reduction is more difficult to

234
achieve among drug users than reduction in risky drug use behaviors

(Lewis and Watters 1991; Lewis et al. 1990; Magura et al. 1990;

McCusker et al. 1993a).

Access and Admission

Outreach and admission policies and procedures need to be considered if

TCs are to attract persons at high risk for HIV. Although it is well known

that substantial numbers of impaired drug users fail to seek treatment

(Rounsaville and Kleber 1985), it also is important to know the extent to

which drug users who are at risk of HIV infection or already infected are

entering treatment. Followup of IDUs who received HIV counseling and

testing at community sites and in prison in central Massachusetts

indicated that a longer history of drug injection, more frequent injection,

bleach use, prior drug treatment, and a positive test result were associated

with admission to drug treatment (McCusker et al. 1994a).

Limited research has compared the characteristics of clients admitted to

TCs with those in other treatment programs and with those not in

treatment. In central Massachusetts, IDUs entering drug treatment were

more likely to be better educated, white, and male than those contacted at

nontreatment sites (McCusker et al. 1990). Even after controlling for

these demographic variables, clients entering treatment reported less risky

drug injection and sexual behaviors than those not in treatment. Alcabes

and colleagues (1992) found that clients in treatment were more likely to

be female, older, white, and have longer injection histories. Other

treatment programs need to assess whether they are admitting lower risk

subpopulations of drug users.

Women may have special problems in accessing treatment, particularly

those who are pregnant or have child care problems (De Leon and

Jainchill 1991). Black and lower socioeconomic status women may be

the least likely to access treatment and may do so only after exhausting

informal resources (Marsh and Miller 1985).

Several studies have found that treatment programs have less success in

attracting younger drug users as well as those who have initiated use

more recently (Fraser and Leighton 1984; Love and Gossop 1985). Thus,

an important window of opportunity to intervene may be lost. Vlahov

and colleagues (1990) suggest that recent IDUs may be at particularly

high risk of HIV infection.

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The characteristics of clients entering treatment differ from one TC to

another, depending on regional demographics and on the program’s

image. These characteristics also may change over time. Among IDUs

entering drug abuse treatment, the proportion of needle sharing has

declined (Guydish et al. 1990; McCusker et al. 1992a; Sorensen et al.

1989 c), and the proportion of needle sharers using bleach has increased

(McCusker et al. 1992a).

Can treatment programs coordinate successfully with outreach programs

that target subpopulations of drug users for priority admission? Three

studies indicate that this is possible. In New Jersey and California, the

distribution of coupons for free detoxification brought many high-risk

drug users into treatment (Jackson et al. 1990; Sorensen et al. 1993). In

Worcester, Massachusetts, drug abuse treatment programs have arranged

to give priority for admission to persons who test positive in a

coordinated, community-based HIV antibody testing program (Centers

for Disease Control 1989; McCusker et al. 1994a).

Some policy issues that need to be addressed include the question of

which subpopulations of drug users should be targeted for admission to

treatment—those at high risk who have not been infected or those already

infected? In communities with low HIV prevalence rates, it may be very

wise to admit HIV-infected drug users preferentially as a way to reduce

the risks of HIV transmission to other users. In communities with very

high rates of HIV infection, the opposite policy might be more effective:

isolate the uninfected from high-risk situations by getting them into

treatment. From a public health viewpoint, it may be most beneficial to

treat those who are important in the heterosexual transmission of HIV

(Holmes et al. 1990). These individuals may tend to be young, inner-city

residents who are involved in the exchange of sex for money or drugs. In

particular, efforts should be directed toward innovative methods of

attracting ethnic minorities into treatment (Schilling et al. 1989a) .

Retention and Outcomes

Methadone maintenance programs have been studied extensively, and

they appear to be effective in reducing intravenous drug use (Ball et al.

1988; Cooper 1989). However, there is marked variation between

programs concerning the reduction of intravenous drug use and needle

sharing. Abdul-Quader and colleagues (1987) found that clients who

stayed longer in methadone maintenance reported lower frequencies of

drug behaviors related to HIV transmission but similar sexual behaviors.

236
In contrast, the effectiveness of TCs in achieving HIV risk reduction has

received little study.

As with other treatment modalities, a longer stay in TC treatment is

associated with a better outcome (De Leon 1984), and only stays of at

least 6 months appear to be associated with a major impact on drug use

(Hubbard et al. 1988). These conclusions are based on nonexperimental

studies, however, and may be explained by selection bias: drug users

with a better prognosis may be retained longer in treatment programs.

Research is needed on the relative effectiveness of shorter treatment

programs, which might allow a larger number of clients to receive

services (Lewis et al. 1993). Preliminary results from two randomized

trials of alternative residential treatment models (6- versus 12-month TC

programs and 3- versus 6-month relapse prevention residential programs)

do not indicate program length effects on psychosocial variables at the

time of exit from the program (McCusker et al. 1994b) or on rates of drug

use or HIV risk behaviors at followup within 6 months of exit (McCusker

et al. 1994c, 1994d ).

The highest attrition rates from TCs occur in the first crucial weeks of

treatment (De Leon and Schwartz 1984), and attrition at this early stage

of recovery is highly likely to be associated with relapse to high-risk

behavior. Research is needed on how TCs can prevent high-risk relapse

among these “treatment failures.” It has been noted that in order to

maintain high-risk IDUs in treatment, methadone maintenance programs

may have to reconsider their policies for discontinuation of clients who

do not comply with requirements for complete abstinence (Batki 1988).

Should TCs also reconsider their policies and assess the effects of policy

changes upon the integrity of the TC?

The associations of HIV status and risky injection behavior with

measures of motivation and readiness for treatment around the time of

admission have been investigated in two New England TCs (McCusker et

al. 1994e). HIV-infected clients appeared to be more motivated than

others, even in multivariable analyses, while riskier behavior had little

effect upon these measures. Studies of the effects of HIV status and risky

behavior on retention and outcomes also are needed. Two studies in

other treatment settings (methadone maintenance and detoxification)

found that HIV status was not associated with retention (McCusker et al.

1992b; Weddington et al. 1991).

237
The effects of TCs upon HIV-relevant behaviors, as well as the more

customary measures of drug addiction, need to be investigated. In one

observational study, clients who were transferred to TCs after

detoxification were less likely to inject drugs at followup compared with

similar clients who were transferred to outpatient treatment or received no

further treatment (McCusker et al., in press-a). These results might be

explained by selection bias, and experimental designs are needed to

address these questions.

HIV Education

Small-group HIV educational programs for drug users have been

developed in a variety of treatment settings: detoxification programs

(Dengelegi et al. 1990; Gibson et al. 1989, 1990; Heitzmann et al. 1989;

McCusker et al. 1992b, in press-c; Sorensen et al. 1990); methadone

maintenance programs (Calsyn et al. 1992; Magma et al. 1989, 1991;

Schilling et al. 1989b; Sorensen et al. 1988,1989a); and TCs (Lewis et

al. 1993; Sorensen et al. 1988,1989b). More limited research has been

reported on individual counseling interventions (Baker et al. 1993). The

setting is probably at least as influential upon outcomes as the HIV

educational program itself, and TCs cannot necessarily adapt apparently

successful programs from other settings (Sorrell and Elion 1989). TCs

have the luxury of a captive audience for a longer period of time than

most other settings, and the challenge is to use this opportunity to its

greatest effect. However, in conducting educational programs in TCs,

one objection is the idea that HIV education that prepares residents for

safe relapse can undermine the abstinence message of TCs (Sorensen et

al. 1991, p. 111).

The principles of health education and the theoretical models that have

been shown to be effective in other settings need to be applied to TCs

(Leviton 1989). Factual knowledge of HIV is not enough in itself for

behavior change (Spencer 1988). Attitudes and beliefs need to be

changed (Jang et al. 1990; Millson et al. 1990), specific skills learned,

and social norms altered (Des Jarlais and Friedman 1988; Sorensen

1990). Interventions based on altering social norms would appear to be

particularly relevant to TCs, which utilize the healing role of the

community.

One study of the effectiveness of HIV educational programs for drug

users in detoxification found evidence of increases in knowledge and

determination to stop drug use but also denial in appraising the risk of

238
personal behaviors (Dengelegi et al. 1990). This same study found

overall risk reduction among program participants at followup. However,

in other studies that have applied experimental designs, the differences

between intervention and control conditions or between standard and

enhanced educational models diminish considerably based on the limited

followup data available so far (Chitwood et al. 1990; Gibson et al. 1990;

McCusker et al. 1993b ; Sorensen et al. 1990). Most studies indicate

improved knowledge, attitudes, intentions, or skills rather than changed

behavior (Sorensen 1991). However, McCusker and colleagues (1993b)

found that while an enhanced intervention was more effective than a

shorter, informational intervention for lower risk drug users, the opposite

was true for IDUs with the most risky behaviors. Further research is

needed to determine which types of interventions are most effective with

which subgroups of drug users. Personality characteristics of high-risk

IDUs may make them more resistant to standard educational approaches

(Brooner et al. 1990, 1993).

Negative or inconsistent outcomes of health education programs are not

unique to HIV education. It is unrealistic to expect more than small,

incremental improvements in behavior to result from interventions that

last only a few hours, particularly when they are set in the context of

powerful treatment programs. Carefully controlled experimental designs

are needed to determine the independent effects of educational programs.

More fundamental changes may need to occur in TCs for greater and

more lasting effects. As an example of this approach, a health education

and relapse prevention program has been developed in a former TC. Two

versions of this program, lasting 3 months and 6 months, currently are

being compared with a more traditional TC. HIV-related behavioral

outcomes are being assessed as well as more conventional measures of

drug use (Lewis et al. 1993).

SECONDARY PREVENTION

The rationale for secondary prevention strategies is that early detection

and prompt treatment will reduce the morbidity and mortality associated

with HIV disease. There is some evidence that early treatment can

increase the incubation period of HIV disease (Harris 1990; Lagakos et

al. 1991). This motivates efforts to identify asymptomatic HIV-infected

persons and to link them with primary care services.

239
HIV antibody screening, partner notification, and antiviral chemotherapy

are interventions that achieve the objectives of secondary prevention. If

HIV screening and treatment are accompanied by a reduction in high-risk

behavior or if treatment reduces infectivity, secondary prevention also

may contribute to primary prevention.

HIV Antibody Testing

HIV antibody testing of IDUs has been debated as an adjunct to other

prevention strategies (Hawthorne and Siegel 1988; Stimmel 1987).

Although Public Health Service guidelines recommend that all IDUs be

routinely counseled and tested (Centers for Disease Control 1988), there

is great variability in testing policies among drug abuse treatment

programs.

In one survey of TC clients, most indicated that they wished to be tested

for HIV (Lewis and Galea 1986). In a survey of clients and staff of four

methadone maintenance clinics in New York City, the majority thought

that voluntary HIV testing should be available and that the results should

be provided to the client’s physician (Curtis et al. 1989). High

participation in an onsite testing program (85 percent) has been reported

from a methadone maintenance program in Minnesota. This rate was

attributed to an awareness of high rates of HIV infection in IDUs, the

voluntary nature of the program, and an indifference to the possible

negative consequences of testing (Carlson and McClellan 1987).

Weddington and Brown (1988) reported on the almost unanimous

acceptance of HIV testing by persons enrolled in an efficacy study of

outpatient treatment for cocaine abuse in Baltimore. In Connecticut,

72 percent of the clients of methadone maintenance programs who

received pretest counseling agreed to be tested, and 87 percent of these

actually had blood drawn (Cartter et al. 1990).

The factors associated with the decision to be tested for HIV have

differed among studies. In a detoxification program in Massachusetts,

those who chose to be tested reported higher risk drug and sexual

behaviors and perceived themselves as more likely to have been infected

than those not tested (McCusker et al., in press-b). These results are

consistent with those found in a prison testing program (Andrus et al.

1989); however, this may not always be the case. In a study of voluntary

versus anonymous testing in a sexually transmitted disease (STD) clinic,

the seroprevalence rate among men who refused testing was over five

240
times greater than that among those who tested voluntarily (Hull et al.

1988).

In a study of HIV testing in a methadone maintenance clinic, clients who

were older, married, and planning to have children were tested more

frequently. The perceived support of the counselor also contributed to

the decision to be tested (Magura et al. 1990). Those clients who

declined to be tested were concerned about breaches of confidentiality

and doubted the value of testing. Assurances of confidentiality or

anonymity are important prerequisites for testing (Kegeles et al. 1990).

However, confidentiality may be difficult to maintain in a TC. Despite

efforts to maintain confidentiality, the emotional impact of a positive test

result would be difficult to hide in the close observation and often intense

encounter group sessions of TCs (Des Jarlais and Friedman 1986).

Limited information is available on the possible adverse effects of testing

IDUs (Clark and Washburn 1988). Casadonte and colleagues (1990)

followed 50 IDUs from before HIV testing to 8 to 10 weeks later and

observed no major stress reactions. Seropositive clients experienced

more anxiety 1 to 2 weeks after learning results. However, this anxiety

gradually diminished, and they made important behavioral changes that

were maintained.

Studies to date indicate minimal evidence that HIV testing is related to

risk reduction (Higgins et al. 1991; McCusker et al., in press-c ; Power et

al. 1988). The behavioral outcomes of IDUs from a program that

combined AIDS education with voluntary HIV testing did not differ from

those of a wait-list control group (Calsyn et al. 1992). Seropositive IDUs

in a Scottish general practice were reported to reduce their frequency of

injection to a greater extent than seronegative IDUs, but this was due to

higher initial frequency in the former (Robertson et al. 1988). Female

seropositive IDUs in Amsterdam reported safer sexual practices than

seronegative IDUs (van den Hoek et al. 1990). However, among

pregnant IDUs informed of their status before 24 weeks of gestation,

Selwyn and colleagues (1989a) found very little difference between HIVinfected and uninfected women regarding their decision to terminate

pregnancy.

Studies are needed that compare the effectiveness of different policies on

HIV antibody testing in TCs. Does testing provide additional motivation

to complete the TC program or does it precipitate attrition? Would

routine HIV testing discourage potential clients from entering the TC?

241
Contact Notification

In TCs where HIV testing is offered, the issue arises of whether, how, and

when to notify needle sharing or sexual contacts of persons who test

positive. One study indicated that routine notification of needle sharing

or sexual partners would differentially discourage HIV-infected IDUs

from entering drug treatment (Rubin et al. 1991). De Philippis and

colleagues (1992) found that the majority of clients in a methadone

program favored contact tracing. Research on this issue in TCs is needed.

Early Treatment

Early in the HIV epidemic, the care of persons with HIV was primarily

the domain of specialist units, particularly departments of infectious

disease. With recent improvements in treatment and standardization of

management protocols, HIV disease has become a “primary care disease

with specialists and experts available to help manage complications”

(Fineberg 1989). However, this transition is problematic for those

HIV-infected groups whose primary care needs clearly have not been met

prior to infection, notably IDUs. Zidovudine appears to be effective in

reducing the rate of progression to AIDS among various groups with

early HIV disease, including IDUs (Lagakos et al. 1991). Improved

survival of AIDS patients initially diagnosed with Pneumocystis carinii

pneumonia also has been reported among IDUs, which may be

attributable in part to better diagnosis and treatment (Harris 1990).

Persons with early HIV disease, along with uninfected persons whose

behavior places them at risk of HIV, ordinarily are managed in primary

care settings, but they may need special programs or personnel or

short-term admission to hospitals for specialized procedures and

investigations (Kanouse et al. 1989). The services needed include staging

and monitoring or referral to these services. Specific treatments that may

be indicated include antiviral drugs (mainly zidovudine) and prophylaxis

against Pneumocystis carinii pneumonia (Wartenberg 1991).

Following discharge from the TC, continuity of primary care is essential

for persons with HIV disease. Provision of primary care for IDUs

presents additional challenges because this population is at risk for a

variety of other acute and chronic conditions, such as tuberculosis, STDs,

and psychiatric problems. The limited research on primary care for IDUs

indicates substantial gaps and barriers. IDUs often are indigent and

inadequately insured. The great majority of IDUs do not receive primary

242
care in the private sector but in public hospitals and clinics and

community health centers (Evans 1990). For many IDUs, the usual

source of care is the emergency room (Solomon et al. 1990).

Service providers often have negative attitudes toward drug users and

their families that reinforce resistant behaviors (Shulman et al. 1990).

Problems such as social instability, frequent lack of suitable family

members or friends who can assist with care, and continued drug use

make IDUs difficult to deal with in both institutional and ambulatory

settings.

A survey of 15 TCs by Des Jarlais and colleagues (1986) found a lack of

consensus on admission policies for persons with HIV disease. Current

policies need to be reassessed and empirical evidence gathered to

compare outcomes for TCs with different admission policies. Both the

effects of clients with HIV disease upon the TC and the effects of the TC

upon HIV-infected clients need to be examined. While there is no

evidence to date that continued drug injection has an adverse effect on the

progression of HIV disease (Margolick et al. 1992), further research is

needed on the effects of TCs on the natural history of HIV.

Several research issues are relevant to TCs. Should clients with early

HIV disease continue to be part of the TC or be transferred elsewhere? If

they remain in the TC, how much, if any, of their primary care needs can

be met within the medical services provided at the TC rather than in the

outside community? What is the role of case management or case

coordination? Finally, careful collaborative arrangements may be needed

with medical centers.

Opportunities also may be available for involvement in clinical trials of

new modalities for treatment of HIV, which offer state-of-the-art

assessment and treatment. It is important for IDUs to participate in these

trials so that the results can be generalized to this population. However, it

has been difficult to obtain access to trials or compliance with trial

protocols among IDUs (Craven et al. 1990). Do TCs have a

responsibility to try to involve their clients in this type of research?

TERTIARY PREVENTION

The onset of advanced HIV disease is heralded by an acute infection or

tumor or the development of wasting syndrome or dementia. Periods of

243
severe illness, often requiring hospitalization, may alternate with periods

of minimal symptoms and normal functioning. The aim of tertiary

prevention is to provide continuing support and care to individuals with

advanced HIV disease in order to reduce mortality and improve quality of

life.

Primary care services are needed as in the earlier stages of HIV, and

previous remarks about access to and coordination of services are equally

applicable to tertiary prevention (Benjamin 1989). Treating people with

HIV disease in drug abuse treatment programs raises many problems, but

there is a compelling need that will grow as HIV disease advances in

those IDUs who are infected. Provision of primary medical care in the

context of drug abuse treatment has been conducted in a few methadone

maintenance programs (e.g., Batki et al. 1990; Selwyn et al. 1989b), but

information also is needed on how TCs are responding to the increasing

burden of advanced HIV disease. Residential programs recently have

begun to address the special problems of treating HIV-infected clients

(Galea et al. 1988a. 1988b; Goldstein and Yuen 1988; Robak and Caffrey

1988).

The availability of intermediate and long-term facilities for persons with

advanced HIV disease who are too ill to live at home but not terminally

ill is grossly inadequate (Taravella 1988), and the problem is exacerbated

for IDUs (Weinberg and Murray 1987). In New Jersey, four TCs

participated in a pilot posthospital residential program for homeless drug

users with symptomatic HIV disease (Jackson et al. 1990). However,

some problems were encountered with programs that were unwilling to

modify their concepts and practices.

Des Jarlais and colleagues (1986) suggested that specialized TCs are

needed for HIV-infected drug abusers. In New York, Samaritan Village

has developed a TC within a long-term care facility providing round-theclock nursing and primary care: H.E.L.P./Project Samaritan, Inc., which

opened in October 1990 (Barton 1992). Residents are former substance

users with AIDS or an opportunistic disease; they must be motivated and

willing to participate as members of a mutually supportive, drug-free TC.

Initial evaluation of this innovative project indicates that more than half

of the residents stay for 6 to 15 months.

Further research is needed on models for meeting the medical and nursing

needs of former substance users with advanced HIV disease within the

TC framework. Should TCs continue to treat residents in the terminal

244
stages of HIV disease, and when should sick residents be transferred to

the hospital or to hospice programs (Bulkin et al. 1988)? Is the presence

of persons with advanced HIV disease a source of motivation for

uninfected clients to complete treatment? Some of the traditional TC

approaches, such as confrontation, may be difficult to enforce with sick

residents. Batki and London (in press) contend that residential programs

will need to increase their flexibility and lower their thresholds for

admission of HIV-infected clients.

RECOMMENDATIONS FOR RESEARCH

The high-priority research questions related to HIV and TCs include the

following:

1.

2.

3.

4.

5.

6.

7.

Are TCs attracting drug users who are at high risk for HIV or already

infected, and how can these admission rates be improved through

outreach and coordination with community programs?

What are the retention rates and outcomes of TCs for persons with or

at high risk of HIV, what are the effects of TCs upon HIV risk

behaviors, and how can these be improved?

Which HIV educational interventions offered to TC clients are more

effective with which subgroups of HIV clients?

How can HIV counseling and testing programs be integrated into

TCs, and what are the effects of these programs upon retention rates

and outcomes of treatment?

Should TCs assist with contact notification for HIV-infected clients,

and what effects might such activities have on admission, retention,

and participation in HIV counseling and testing programs?

How can TCs best provide medical and other services to

HIV-infected clients, and what effects do such services have on the

rates of progression to AIDS and survival?

What modifications, if any, should TCs make to accommodate clients

with HIV disease, and what effects do such modifications have on

clients with and without HIV disease?

245
CONCLUSIONS

This chapter has reviewed the HIV-related issues that confront TCs. At

this early stage, there are more questions than answers. There are some

highly charged issues that need to be worked through before TCs can turn

their full force to bear on managing the HIV epidemic. The ability of

TCs to respond to the many challenges of the HIV epidemic will depend

on many factors, including size, budget, location, and structure (Marco

1989). The attitudes and training of staff will be a key determinant of

success (Galea et al. 1988a). Knowledge of what does and does not work

is at an early stage. Greater coordination among TCs and standardization

and documentation of different approaches are needed.

In summary, HIV disease is a chronic problem with a substantial

incubation period. As HIV advances among hundreds of thousands of

drug users who already are infected, they will be in need of residential

care. TCs will have an increasingly important role to play, if the difficult

issues can be worked out now.

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Outcomes of inpatient drug detoxification: Retention, transfer to

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McCusker, J.; Bigelow, C.; Stoddard, A.; Vickers-Lahti, M.; Hindin, R.;

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ACKNOWLEDGMENTS

Ellen McCarthy, M.P.H., assisted with the literature search. This work

was supported in part by NIDA grants R01-DA-04508A and

IR18-DA-06097.

AUTHORS

Jane McCusker, M.D., Dr.P.H.

Head

Department of Clinical Epidemiology and Community Studies

St. Mary’s Hospital Center

3930 Lacombe Avenue, Room 2508

Montreal, PQ

H3T lM5 Canada

257
James L. Sorensen, Ph.D.

Adjunct Professor

Department of Psychiatry

University of California, San Francisco

and

Chief of Substance Abuse Services

San Francisco General Hospital

1001 Potrero Avenue

San Francisco, CA 94110

258
Therapeutic Communities in

Corrections and Work Release:

Some Clinical and Policy

Considerations

James A. Inciardi, Dorothy Lockwood, and Steven S. Martin

INTRODUCTION

The primary task of prisons, despite any arguments to the contrary, is

custody. The internal order of the prison is maintained by strictly

controlling the inmates and regimenting every aspect of their lives. In

addition to their loss of freedom and basic liberties, goods and services,

heterosexual relationships, and autonomy, they are deprived of their

personal identities. Upon entering prison, inmates are stripped of their

clothing and most of their personal possessions; they are examined,

inspected, weighed, documented, classified, and given a number. Thus,

prison becomes painful both physically and psychologically (Clemmer

1958; Sykes 1965).

The rigors and frustrations of confinement leave but a few paths open to

inmates. They can bind themselves to their fellow captives in ties of

mutual aid and loyalty, in opposition to prison officials. They can wage a

war against all, seeking their own advantage without reference to the

needs and claims of others, or they can simply withdraw into themselves.

Ideally these alternatives exist only in an abstract sense, and most inmates

combine characteristics of the first two extremes. Within this balance of

extremes, an inmate social system emerges and functions, and one of the

fundamental elements of this social system is the prison subculture.

Every correctional facility has its subculture, and every prison subculture

has its system of norms that influence prisoners’ behavior, typically to a

far greater extent than the institution’s formally prescribed rules. These

subcultural norms are informal and unwritten rules, but their violation can

evoke sanctions from fellow inmates ranging from simple ostracism to

physical violence and death. Many of these rules revolve around

relations among inmates and interactions with prison staff, while others

reflect preoccupations with being smart, tough, and streetwise. As such,

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this prison code often tends to militate against reform in general and drug

rehabilitation in particular.

In addition, there are many other phenomena in the prison environment

that make rehabilitation difficult. Not surprisingly, the availability of

drugs in prisons is a pervasive problem. Moreover, in addition to the

one-on-one violence that seems to be a concomitant of prison life, there is

the violence associated with inmate gangs. These gangs often are formed

along racial lines for the purposes of establishing and maintaining status,

turf, and unofficial control over certain sectors of the penitentiary.

Within this kind of a setting, it would appear that if any drug

rehabilitation approach had a chance of succeeding, it would be the

therapeutic community (TC). The TC is a total treatment environment

that is isolated from the rest of the prison population-separated from the

drugs, the violence, and the norms and values that rebuff attempts at

rehabilitation.

THE STAGING OF CORRECTIONS-BASED TC TREATMENT

Based on prior experience with correctional systems and populations,

with corrections-based drug treatment, and with the evaluation of a

variety of correctional programs, it would appear that the most

appropriate strategy for effective TC intervention with inmates would

involve a three-stage process. Each stage in this regimen of treatment

would correspond to the inmate’s changing correctional status—

incarceration, work release, and parole (or whatever other form of

community-based correction operates in a given jurisdiction).

Primary TC Treatment

The primary stage should consist of a prison-based TC designed to

facilitate personal growth through the modification of deviant lifestyles

and behavior patterns. When inmates are segregated from the rest of the

penitentiary, their recovery from drug abuse and development of

prosocial values in the prison TC involve essentially the same

mechanisms seen in community-based TCs.

As in other TCs, therapy in this primary stage should be an ongoing and

evolving process. Ideally, it should endure for 9 to 12 months, with the

potential for the resident to remain longer, if necessary. As such, recruits

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for the TC should be within 18 months of their work release date at the

time of treatment entry.

It is important that TC treatment for inmates begin while they are still in

the institution, for a number of reasons. In a prison situation, time is one

of the few resources that most inmates have in abundance. The

competing demands of family, work, and the neighborhood peer group

are absent. Thus, there is the time and opportunity for comprehensive

treatmentperhaps for the first time in a drug offender’s career. In

addition, there are other new opportunities presented—to interact with

“recovering addict” role models; to acquire prosocial values and a

positive work ethic; and to initiate a process of education, training, and

understanding of the addiction cycle.

Secondary TC Treatment

Since the 1970s, work release has become a widespread correctional

practice for felony offenders. It is a form of partial incarceration whereby

inmates are permitted to work for pay in the community, but they must

spend their nonworking hours either in the institution or, more

commonly, in a community-based work release facility or halfway house.

Inmates qualified for work release are those approaching their parole

eligibility or conditional release dates. Although graduated release of this

sort carries the potential for easing an inmate’s process of community

reintegration, there is a negative side, especially for those whose drug

involvement served as the key to the penitentiary gate in the first place.

This initial freedom exposes many inmates to groups and behaviors that

easily can lead them back to substance abuse, criminal activities, and

reincarceration. Even those receiving intensive TC treatment while in the

institution face the prospect of their recovery breaking down. Work

release environments in most jurisdictions do little to stem the process of

relapse. Since work release populations mirror the institutional

populations from which they came, there are still the negative values of

the prison culture. In addition, street drugs and street norms tend to

abound.

Graduates of prison-based TCs are at a special disadvantage in a

traditional work release center since they must live and interact in what

typically is an antisocial, nonproductive setting. Without clinical

management and proper supervision, their recovery can be severely

threatened. Thus, secondary TC treatment is warranted. This secondary

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stage is a “transitional TC”—the TC work release center or TC halfway

house.

The program composition of the work release TC should be similar to

that of the traditional TC. There should be the “family setting,” which is

removed from as many of the external negative influences of the street

and inmate cultures as is possible. There also should be the hierarchical

system of ranks and job functions, the rules and regulations of the

environment, and the complex of therapeutic techniques designed to

continue the process of resocialization. However, the clinical regimen in

the work release TC must be modified to address the correctional

mandate of “work release.”

Tertiary TC Treatment

In the tertiary stage, clients will have completed work release and will be

living in the community under the supervision of parole or some other

surveillance program. Treatment intervention in this stage should involve

outpatient counseling and group therapy. Clients should be encouraged

to return to the work release TC for refresher or reinforcement sessions,

to attend weekly groups, to call on their counselors on a regular basis, and

to participate in monthly one-on-one or family sessions. They also

should be required to spend 1 day each month at the program and to

attend a weekend retreat every 3 months.

CREST OUTREACH CENTER

During the closing months of 1990, the Center for Alcohol and Drug

Studies at the University of Delaware was awarded a 5-year National

Institute on Drug Abuse (NIDA) treatment demonstration grant to

establish a work release TC. Known as CREST Outreach Center, the

authors believe that it represents the first dedicated work release TC in the

Nation, and it has been designed to incorporate the three-stage treatment

process just described. Such a staging process is possible since a prisonbased TC already exists in Delaware.

The treatment regimen at CREST Outreach Center follows a five-phase

model over a 6-month period. Phase One is composed of entry,

assessment and evaluation, and orientation, and it lasts approximately

2 weeks. New residents are introduced to the house rules and schedules

by older residents. Each new resident also is assigned a primary

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counselor who initiates an individual needs assessment. Participation in

group therapy is limited during this initial phase so that new residents can

become familiarized with the norms and procedures at CREST.

Phase Two emphasizes involvement in the TC community, including

such activities as morning meetings, group therapy, one-on-one

interaction, confrontation of other residents who are not motivated toward

recovery, and nurturance of the newer people in the environment. During

this phase, residents begin to address their own issues related to drug

abuse and criminal activity during both group sessions and one-on-one

interactions. Also, they begin to take responsibility for their own

behaviors by being held accountable for their attitudes and actions in

group settings and in informal interactions with residents and staff.

Residents are assigned job functions aimed at assuming responsibility and

learning acceptable work habits, and they continue to meet with their

primary counselors for individual sessions. However, the primary

emphasis in Phase Two is on becoming an active community member

through participating in group therapy and fulfilling job responsibilities

necessary to facility operations. This phase lasts approximately 8 weeks.

Phase Three continues the elements of Phase Two and stresses rolemodeling and overseeing the working of the community on a daily basis

(with the support and supervision of the clinical staff). During this phase,

residents are expected to assume responsibility for themselves and to hold

themselves accountable for their attitudes and behaviors. Frequently,

residents in this phase will confront each other in group settings. They

assume additional job responsibilities by moving into supervisory

positions, thus enabling them to serve as positive role models for newer

residents. They continue to have individual counseling sessions, and in

group sessions they are expected to help facilitate the group process.

Phase Three lasts for approximately 5 weeks.

Phase Four initiates preparation for gainful employment, including

participating in mock interviews, attending seminars on job-seeking,

making the best appearance when seeing a potential employer,

developing relationships with community agencies, and looking for ways

to further educational or vocational abilities. This phase focuses on

preparing for reentry to the community and lasts approximately 2 weeks.

Residents continue to participate in both group and individual therapy

and to be responsible for their jobs in the CREST facility. However,

additional seminars and group sessions are introduced to address issues

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related to finding and maintaining employment and housing as well as

returning to the community environment.

Phase Five involves reentry, that is, becoming gainfully employed in the

outside community while continuing to live in the work release facility

and serving as a role model for those at earlier stages of treatment. This

phase focuses on balancing work and treatment. As such, both becoming

employed and maintaining a job are integral aspects of the TC work

release program. During this phase, residents continue to participate in

program activities, such as seminars and social events. They also

participate in group sessions that address issues of employment and

continuing treatment after leaving CREST. In addition, residents begin to

prepare to leave CREST. They open a bank account and begin to budget

for housing, food, and utilities. Seven weeks into Phase Five,

representing a total of 26 weeks at CREST Outreach Center, residents.

have completed their work release commitment and are free to live and

work in the community as program graduates.

Throughout the program process, residents in different stages of their

recovery regularly interact with one another. The CREST Outreach

Center community is comprised of both women and men at a variety of

stages of treatment. Through this interaction, newer residents are given

hope and encouragement for changing their lifestyles, and the older

residents can assess their own changes and become positive role models.

Moreover, beginning in Phase Two, residents are encouraged to engage

family and significant others in the treatment process through family and

couples groups led by CREST counselors.

In all phases of treatment at CREST, urine is monitored on a regular but

unscheduled basis. Since urine monitoring is an aspect of standard

Department of Correction (DOC) work release procedure, sanctions for

urines testing positive for illicit and nonprescribed drugs are imposed by

DOC staff following DOC guidelines. Typically, positive urines on more

than two occasions can result in cancellation of work release and return to

the institution. However, although all work release participants are under

the supervision and custody of Delaware DOC, CREST Outreach Center

is operated by University of Delaware personnel. The only correctional

presence at CREST is a periodic walk-through by a single correction

officer.

264
All CREST graduates are urged to return to the facility periodically to

participate in the groups, one-on-one interactions, family sessions, and

retreats that represent stage three of prison-based TC treatment.

RESEARCH AND TREATMENT IMPLICATIONS

Since CREST Outreach Center was established as part of a NIDA

treatment demonstration grant, the opportunity exists to evaluate the

clinical efficacy of alternative models of the TC work release concept.

Over the 5-year grant period, CREST will serve 360 inmates; 260 of

these will be selected from the general prison population eligible for work

release. Over this same period of time, 100 residents of the Key,

Delaware’s prison-based TC, will be placed in the TC work release

program, providing a transitional placement for these individuals.’

Results for each of these groups will be compared to a control group of

260 residents of the existing work release centers—Plummer Center in

Wilmington and Sussex Work Release in lower Delaware. Subject

selection into the treatment and control groups is random and compatible

with the DOC’s current process for placement into work release. The

study population will be 20 percent female and 80 percent male, with an

ethnicity makeup reflecting that of the general institutional population.

All 620 subjects will receive human immunodeficiency virus (HIV) and

urine testing immediately prior to work release, assessments of drug use

and HIV risk behavior histories, and intensive acquired

immunodeficiency syndrome prevention education over the 30-day

period prior to work release placement. All 620 subjects will be followed

up at the completion of work release and at two subsequent intervals of

6 and 12 months after work release fulfillment. At each followup point,

all 620 subjects will receive HIV and urine testing as well as

questionnaire reassessment about drug use, criminal activity, and HIV

risk behavior.

Finally, since the Key TC has been in operation since 1988 and many of

its initial clients graduated to conventional work release prior to formal

intake at CREST, the opportunity exists to make comparisons between a

one-stage model of TC intervention (prison-based TC only), a two-stage

model (CREST plus the outpatient phase for CREST graduates), and a

three-stage model (prison TC plus CREST and post-CREST outpatient

counseling).

265
Specific recommendations for either treatment or research are impossible

at this juncture. However, the findings from the study, of which CREST

is the treatment component, promise to provide concrete data on the

impact of treatment on both drug use and on criminal activity. This

research also will produce knowledge on the TC process, providing a

better understanding of what goes on in a TC and who benefits most from

this type of treatment. This information is necessary in order to expand

and improve treatment for drug-involved offenders. Without increased

and improved treatment opportunities, the trend toward warehousing

criminals will continue, resulting in increased recidivism rates, larger

prison populations, and, eventually, more prisons.

NOTE

1. The Key TC was established in Delaware’s Multi-Purpose Criminal

Justice Facility during July 1988. Initially funded through a Bureau

of Justice assistance grant and currently supported by the State of

Delaware, the program houses 70 men in a section of this maximumsecurity facility that is totally isolated from all other inmates.

Residents of the program must be within 18 months of parole

eligibility or work release in order to enter the Key, and the treatment

regimen is similar to that of most community-based TCs (Lipton and

Wexler 1988).

REFERENCES

Clemmer, D. The Prison Community. New York: Rinehart and Co., 1958.

Lipton, D.S., and Wexler, H.K. Breaking the drugs-crime connection.

Corrections Today August:l44-146, 1988.

Sykes, G.M. The Society of Captives: A Study of a Maximum Security

Prison. New York: Atheneum, 1965.

266
AUTHORS

James A. Inciardi, Ph.D.

Director

Dorothy Lockwood, Ph.D.

Associate Director

Steven S. Martin, M.A.

Associate Scientist

Center for Alcohol and Drug Studies

77 East Main Street

University of Delaware

Newark, DE 19716

267
Clinical Issues in Therapeutic

Communities

Jerome F.X. Carroll

INTRODUCTION

The initiative exercised by the National Institute on Drug Abuse (NIDA)

in bringing together researchers who have conducted studies in

therapeutic communities (TCs) with TC administrators and clinicians is a

very encouraging sign that the recent hiatus in generating significant

research studies specific to TCs may end. Even more exciting is the

possibility that future studies undertaken with NIDA support would entail

a similar collaborative effort at every level, including: (1) the framing of

relevant and important research questions; (2) the identification of

existing data and the generation of new data for study; (3) the

identification and selection of appropriate instruments and strategies for

acquiring the desired data; (4) the design and implementation of the study

in order to minimize any program disruptions or negative impact the

study might have on clients (researchers still will be responsible for

statistical design and analysis of the data); and (5) the interpretation of the

data.

NIDA needs to continue this initiative by fostering greater contact

between researchers and TCs. Too often, research initiatives are fairly

well formulated by the time researchers contact a TC—usually for

subjects. At that point, it is too late to make meaningful suggestions

regarding design modifications, nor is there much meaningful dialog

about instrumentation or the interpretation of findings. Hence, many past

research efforts have failed to realize their fullest potential to enlighten

the field, to sharpen conceptions of addiction and rehabilitative practices,

and to point the way for future studies.

Regarding future technical reviews, the author suggests that the

conference format could be modified so that the TC administrators and

clinicians are afforded “more air time” and are consulted earlier in the

discussion process. In addition, both researchers and TC people need to

be more aware of their jargon. Jargon is a major impediment to good

communication and collaboration. With very few exceptions, technical

concepts can be translated into commonly understood language.

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At another level, collaboration also should include the involvement of the

National Institute on Alcohol Abuse and Alcoholism and the National

Institute of Mental Health, since the overwhelming majority of TC clients

abuse or have abused alcohol and as a consequence have experienced

considerable emotional distress—both as a precursor to addiction and as a

consequence of their addiction.

The concern and suggestions cited above are equally salient with respect

to program evaluation. There is a very strong concern within the TC field

that various external powers will impose impossible or irrelevant program

evaluation standards on TC programs. The TC field is neither adverse to

nor afraid of evaluation and fully understands that such evaluations are

necessary and even desirable. However, to achieve a mutually agreed

upon goal of quality program evaluation, there must be collaboration

between the regulatory/funding authority and the programs in framing the

goals, criteria, and procedures to be employed in evaluations as well as in

determining the training, selection, and qualifications of those who would

carry out the evaluations.

TCs are unlike any other variety of human services delivery systems.

Their uniqueness needs to be reflected in program evaluation standards,

and the fashioning of such standards can only be accomplished through

thoughtful, collaborative efforts. Nothing would be more detrimental to

those who are struggling to deliver quality services to a difficult and

demanding clientele under conditions of diminishing resources and

support than to have seemingly irrelevant or impossible standards set by

what appear to be unconcerned, insensitive, and misinformed regulatory

authorities.

GENERAL OBSERVATIONS REGARDING CLINICAL ISSUES

First and foremost, some very fundamental questions need to be answered

by well-designed and executed studies. For example, there is

considerable diversity among the Nation’s TCs, although “at the core”

they share a common philosophy of addiction and recovery and employ

similar clinical interventions. During the technical review, Dr. George

De Leon provided a list of common elements that characterize and define

a TC. Regardless of what TCs do or do not have in common, it is

imperative to acknowledge the tremendous changes that have taken place

in TCs over the last decade. However, TCs have not uniformly adapted

to these changes. A survey of the TC field needs to be done in order to

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ascertain the guiding principles and practices that currently distinguish

this field.

Generally, it is acknowledged that the field has become “more

professional.” Typically this means that more traditionally trained and

educated professionals now work, in one capacity or another, in TCs;

however, the extent and nature of their integration is not known.

Becoming more professional also has other meanings, including the

establishment of traditional and customary uniform personnel practices,

fiscal accountability, quality assurance, utilization and review, case

conferencing, interdisciplinary team work, program evaluation, employee

assistance programs, continuing education requirements, staff

development and training programs, and so forth. To what extent have

TCs adopted such practices? It simply is not known.

Another fundamental question is “Who is being treated?” Again there is

an enormous breadth and diversity of clients being treated in TCs, which

reflects, in part, the great differences in the formal and informal

admissions standards employed by TCs. Some TCs admit pregnant

women-others do not; some admit mentally ill chemical abuser (MICA)

clients-others do not; some admit human immunodeficiency virus

(HIV)-positive clients—others do not; and some admit clients with

physical disabilities—others do not. To complicate matters further, even

when certain TCs claim not to be admitting a particular type of client

(e.g., a MICA client), they may be admitting them without really

knowing it. A careful survey of just whom TCs are serving is needed.

A related fundamental question is “How much treatment is needed?”

Most reports at the technical review indicated a strong, positive

correlation between length of stay (LOS) in TC treatment and positive

treatment outcomes. However, some adjustment in understanding and

applying this precept as an article of faith is needed. Many cases abound

that indicate that individuals who have completed a full course of TC

treatment, including graduation, and then relapsed, would benefit from a

relatively shorter LOS in residential treatment. Furthermore, the LOS

concept needs to be broadened to include outpatient and self-help

involvement. Finally, without more care in assessing client

characteristics—type, severity, and duration of addiction; co-morbidities;

problems-in-living; and the variety of treatment experiences, including

frequency, duration, and an indication of who delivered the service and

the quality of that service—the field cannot advance much beyond

enunciating that LOS is an important consideration in recovery.

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“What treatment/rehabilitative services and healing experiences are

taking place in TCs?” is another question to be addressed. Besides basic

community/focus meetings, confrontation, emotionality (groups that

focus on feelings), extended sessions, marathons, and work assignments

and tasks, there are many “adjunctive” services now available in TCs.

However, there is little indication of their nature and utilization. A

cursory list of some recent “add-ons” would include: relapse prevention,

incest survival, grief, and relaxation groups; assertiveness training;

human sexuality; and social skills groups. Specialized services also

available in some programs include psychiatry, psychology, recreation

therapy, remedial education, vocational rehabilitation, on-the-job training,

legal counseling, medical and nursing services, and family therapy.

A number of TCs have devised special programs for special populations

(e.g., MICAS, gays and lesbians, Vietnam veterans with post-traumatic

stress disorder (PTSD) co-morbidity, women, women with children, and

adolescents). Most such programs segregate these special population

clients from other substance abusing clients. Other TCs “mainstream”

these special populations; that is, they are mixed in with the general

population except for the times they receive special services designed to

meet their unique needs. Which approach works best for whom, in what

type of TC? Research and program evaluation studies are needed to

answer these questions.

To complicate understanding of the healing power of a modem TC even

more, when residents are asked what one thing most helped them on their

way to recovery, they often answer, “my peers.” This is a humbling

experience for anyone who tends to think that it is primarily the work,

dedication, and skills of the TC staff that make the vital difference.

Another recent development of note is the fact that more recovering

substance abuse counselors are returning to school to obtain traditional

academic and professional degrees. Thus, when research tries to explore

the relative contribution of “having been there” versus professional

education and training, the question becomes both more difficult to

answer and less relevant.

CO-MORBIDITIES AND MULTIPLE SUBSTANCE ABUSE

Today the convoluted nature of addiction is routinely acknowledged.

Once drinking alcohol was given little attention or even condoned and

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encouraged; now nearly everyone appreciates the great risk of alcohol

abuse and alcoholism associated with recovering addicts’ attempting

social drinking. There also is growing recognition of the significance of

early periods of alcohol abuse; the use of alcohol as a substitute drug for

one’s “drug of choice”; the use of alcohol to boost, balance, counteract, or

sustain the effects of another drug; and the major role that alcohol plays

in relapse, especially during the early stages of recovery. More research

is needed to document and clarify the interplay between alcohol and drug

abuse.

Multiple substance abuse is the rule, not the exception (Carroll 1980;

Carroll et al. 1980; Carroll and Ottenberg 1982). Programs should not

gear treatment to confronting a single drug of abuse or drug abuse

category; this principle applies for both drug-free and methadonemaintenance programs. For example, drug programs need to be capable

of treating drug addicts who abuse alcohol; methadone-maintenance

programs must be able to address the abuse of both alcohol and drugs

other than opioids. The impact of the extent to which programs address

this phenomenon needs to be examined.

Co-morbidity also is a fact of life; most substance abusers present with

one or more additional physical or mental disorders at admission.

Although a number of researchers have addressed this issue within

specific programs, few have investigated the array of co-morbidities

across programs and across regions. This task needs to be accomplished.

Are clients “sicker” today than in the past? Physically, there can be no

question about the answer; acquired immunodeficiency syndrome (AIDS)

would force an affirmative answer. With respect to psychological

distress, however, the answer is more ambiguous. Some researchers have

suggested that today’s clients are more distressed. The author’s clinical

experience suggests that clients have remained more or less the same,

which does not diminish the significance of the other position, since both

positions acknowledge considerable levels of psychological distress (see

table 1). Unfortunately, this question is hard to answer via research

studies, since historical data regarding psychopathologies are not readily

available or easily accessible.

In three survey studies (Carroll et al. 1982; Carroll and Klein 1974;

Jainchill, personal communication, 1989-90) that employed the

Tennessee Self Concept Scale (TSCS) (Fitts 1965) to assess the extent of

unhealthy self-concepts among addicts in residential treatment, it was

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TABLE 1. Comparative findings of psychopathology among substance abusers, 1977-1991

KEY: * All admissions to Eagleville Hospital in 1977, unpublished study; ** Eagleville Hospital’s Continuum Program (45 subjects),

unpublished study; *** Project Return Foundation’s (PRF’s) entire Orientation Program (69 subjects), unpublished study; + All

clients in PRF’s Residential Drug-Free Programs 21 days LOS (372 subjects), unpublished study.
observed that the mean Total Positive Scores consistently fell within the

same clinical level of psychopathology (see figure 1); that is, between the

first and second standard deviations below the mean or between the 10th

percentile and 5th percentile. It is interesting to note that in the survey by

Carroll and colleagues (1982), the lowest mean Total Positive Score

(T = 32) was obtained by clients who mainly abused alcohol and

secondarily abused drugs. If one extends the meaning of co-morbidity to

include nonphysical defects that impair functioning, such as major

reading, writing, and calculating deficiencies and inadequate work skills,

attitudes, and little or no legitimate work experience, the need for a near

total restructuring of clients’ values, beliefs, feelings, and behaviors

becomes obvious. Considerably more research is needed to assess the

full impact of various co-morbidities on the treatment of addiction.

SOME CONCLUSIONS

The above observations call for comprehensive, holistic treatment

programs in TCs; that is, programs that employ multidisciplinary teams

capable of delivering individualized, effective, and high-quality

treatment. It is necessary to know the extent to which such programs are

available in the TC field. Furthermore, if such programs exist, it is

important to examine how harmoniously and effectively the various

components (discipline and treatment modules) are integrated and how

effective this treatment is in addressing the individual treatment goals and

objectives of clients.

The author advocates turning to the organization and development field

for measures of leadership style, a sense of shared mission,

communication styles, decisionmaking systems, employee morale and

burnout, and program flexibility and adaptability. These program or

ecologically oriented variables exert tremendous influence on the

effectiveness of treatment and thus affect outcome. Research is

desperately needed in this area.

The author recently received a copy of Operation PAR’s Community

Orientation Program Environment Scale. This scale measures the

following variables: involvement, support, spontaneity, autonomy,

practical orientation, personal problem orientation, clarity, and staff

control. This instrument is attuned to TC life and therapeutics, and it

illustrates the type of instrumentation that can be employed to do

ecologically oriented research.

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FIGURE 1. Tennessee Self Concept Scores of chemically dependent persons across three decades
It is critically important to demonstrate the value of treatment and that

treatment works. Although some tentative steps have been taken in this

regard, they are not enough. Everyone in the substance abuse field is

continually asked: “What is your success rate?” Each individual

struggles to find a “sound bite” answer to this very complex question,

mainly because those who ask this question often have too little time or

patience to hear what is said, or their experience with addiction is too

limited to appreciate a careful, thoughtful, and honest reply. The former

director of the Office of National Drug Control Policy, Bob Martinez,

clearly stated this priority during an interview: “I happen to believe there

is a future in treatment, but I also believe we’re going to have to do a

better job of quantifying it to sell it to those who are in a position of

providing either private or public funds” (Martinez 1991, p. 2).

What constitutes “success” in this field? How does a TC administrator

determine how well his or her program is doing in delivering the services

that clients most need to successfully rehabilitate their lives? The TC

field, at least, has come to appreciate that success or failure cannot be

equated in some simplistic way with any absolute measure of total and

permanent abstinence. It is a well-known fact that a very high percentage

of clients will attempt some form of “controlled use” of psychoactive

substances (usually alcohol and/or marijuana) at some point after

completing treatment. To assess treatment success or failure, therefore, it

is necessary to take account of the client’s life circumstances at the time

he or she begins using again, as well as whether he or she has been

involved in any form of aftercare treatment (e.g., Alcoholics Anonymous

(AA), Narcotics Anonymous (NA), or informal continuing contact with

TC treatment staff) prior to relapsing. In considering any relapse as an

indicator of treatment outcome, the nature, extent, severity, and duration

of the relapse also must be considered. The author argues that someone

who begins to use again, experiences distress connected with this use, and

within a matter of hours or days calls his or her NA/AA sponsor or

former TC counselor to get help and as a consequence resumes his or her

abstinence is a “success.”

The author believes that even the view of “dropouts” is beginning to

become less absolute. For example, Dr. Benjamin Lewis, at NIDA’s

technical review, reported that all dropouts are not the same; that is, they

do not all suffer the same negative fate. Some individuals apparently do

better than others after dropping out of treatment. This coincides with the

author’s experience at Project Return, where some dropouts seem to be

holding down jobs, attending NA groups, and self-reporting abstinence.

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The author also believes that TC administrators, clinicians, and

researchers need to develop intermediate outcome measures as well as

completed outcome measures of treatment success. At Project Return,

Behavioral Criteria (BC) are utilized for each of the TC levels. The BCs

spell out in clear, concise language what behaviors are expected from the

client at each level. The client’s counselor rates the client every week in

orientation and every other week in the other levels by using a simple

five-point scale, where a rating of one indicates poor progress and a

rating of five indicates excellent progress. Clients remain in a level until

their overall (average) rating is three for the criteria for that level.

Other intermediate outcome measures that could be tapped include

advancing a grade level in remedial education, obtaining a General

Equivalency Diploma, completing a vocational training course, obtaining

a job (noting weekly or monthly wages earned and taxes paid), noting the

number of level movements achieved, the number. and percentage of

clean urines taken, and the number of drug/alcohol-free days on days-atrisk. At NIDA’s technical review, Dr. Lorand Szalay (1983) described

one such measure, the Associative Group Analysis, which could be used

for either an intermediate or completed outcome measure.

An indepth, carefully planned national study of life after formal treatment

ends is desperately needed. Research staff need to be recruited to go into

the communities where former clients live and assess what is happening

to them in their communities as well as in their families, on their jobs, or

at their schools. In such an undertaking, multiple measures over time are

needed across both personal and environmental variables.

New models of addiction and recovery also need to be developed. The

old disease model, while an improvement over the concepts of sin, crime,

and lack of willpower, is woefully insufficient for use in the next decade

and next century. The author has advocated that the addictions field

adopt and promulgate an “ecological dysfunction” model (Carroll 1975).

This model can be expressed by the following formula:

B=f(P E).

Behavior (B), such as becoming addicted or recovering from an

addiction, is a function (f) of the reciprocal influence ( ) of person (P)

variables (e.g., genetics, diet, physiology, learning, and personality) and

environmental (E) variables (e.g., substance abuse in the family, poverty,

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racism, sexism, dysfunctional family relationships, job stress, and

neighborhood norms regarding substance use and abuse).

Significant environmental influences often are neglected in research

design, most likely because they are not very amenable to manipulation

or tight statistical control. Moreover, policymakers know full well that

the “solution” to a problem, such as addiction, would be simpler if it

could be demonstrated that something “wrong” in the person was the real

cause of the problem. This may explain why medically oriented research

tends to get the lion’s share of the research dollars. In conclusion,

NIDA’s initiative is to be commended—provided that subsequent

collaborative meetings occur to advance the process begun in this

technical review.

REFERENCES

Carroll, J.F.X. “Mental illness” and “disease”; outmoded concepts in

alcohol and drug rehabilitation. Community Ment Health J 11(4):

418-429, 1975.

Carroll, J.F.X. Uncovering drug abuse by alcoholics and alcohol abuse by

addicts. Int J Addict 15(4):591-595, 1980.

Carroll, J.F.X., and Klein, M.I. “A Comparative Study of the Personality

Characteristics of Alcohol and Drug Dependent Males.” Paper

presented at the research and training section of the 25th annual

meeting of the Alcohol, Drug Problems Association, San Francisco,

December 1974.

Carroll, J.F.X.; Malloy, T.E.; and Kendrick, F.M. Multiple substance

abuse: A review of the literature. In: Gardner, S.E., ed. National

Drug/Alcohol Collaborative Project: Issues in Multiple Substance

Abuse. DHEW Pub. No. (ADM)80-957. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1980. pp. 9-24.

Carroll, J.F.X.; Malloy , T.E.; Roscioli, D.; Pindjak, G.M.; and Clifford,

J.S. Similarities and differences in self-concepts of alcohol and drug

addicted women. J Stud Alcohol 43(7):725-738, 1982.

Carroll, J.F.X., and Ottenberg, D.J. Combined treatment of alcoholism

and drug addiction. In: Solomon, J., and Keeley, K.A., eds.

Perspectives in Alcohol and Drug Abuse: Similarities and

Difirences. Boston: John Wright, PSG, 1982. pp. 117-144.

Fitts, W.H. Manual for the Tennessee Self Concept Scale. Nashville:

Counselor Recordings and Tests, 1965.

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Martinez, B. Providers must show success, be pros to earn support.

Alcohol and Drug Abuse Week 3(22):1-3, 1991.

Szalay, L.B., and Maday, B.C. Implicit culture and psychocultural

distance. Am Anthropol 85:101-116, 1983.

AUTHOR

Jerome F.X. Carroll, Ph.D.

Chief Clinical Officer

Project Return Foundation, Inc.

10 Astor Place

New York, NY 10003

279
Therapeutic Community Research

and Practice: Recommendations

Frank M. Tims, George De Leon, and Nancy Jainchill

INTRODUCTION

The technical review meeting from which this monograph resulted was

convened to accomplish several objectives. These objectives included the

systematic review of existing research on therapeutic community (TC)

treatment and development of a set of recommendations for future

research. It is important to note that while the emphasis of the meeting

was on treatment research, this research cannot be carried out

successfully without the active cooperation of the clinicians and

administrators who are responsible for the direction of treatment and who

will ultimately make the decisions on how research findings are

implemented. Researchers who do not understand and respect the

legitimate interests and concerns of providers risk losing both the

cooperation necessary to conduct research and their own ability to

properly frame the most meaningful research questions. Just as the most

productive approach to conducting and applying research in TCs entails

partnership among researchers, clinicians, and administrators, the

identification of research questions and priorities also must involve all

three.

Thus, the recommendations that follow are based not only on the state of

the research, but also on the consensus reports from three panels who

participated in the meeting: the research panel, the administrative panel,

and the clinician panel. The two latter panels, which were composed of

invited discussants (i.e., directors of TC programs and key clinical staff

from programs), were asked to identity issues of research having the

greatest potential applied significance from their own perspectives. The

three panels then were asked to develop recommendations based on the

existing state of knowledge, major gaps in knowledge, needs of the field,

and strategies for improving both knowledge and its application to

treatment. They also were asked to consider requirements for developing

an environment to foster research and utilization of research to improve

treatment in TCs. Further recommendations are identified in the

individual chapters in this volume, and some of these have been included

280
in the following summary. In general, however, the more subject-specific

recommendations are found in the individual chapters.

RESEARCH FOCUS

1.

2.

3.

4.

5.

6.

7.

Continue to research treatment outcome, both in large studies such as

the Drug Abuse Treatment Outcome Study (DATOS), and in

program-based and collaborative studies.

Conduct research on process and outcome in an orderly way,

building a systematic body of knowledge. Clarification of treatment

process is now possible because of treatment outcome studies that

have been completed. Process studies should focus on better

definition of the treatment process and development of measures and

instrumentation. Studies should include measures that enable

researchers to relate changes in client functioning to stages of the

treatment process and the underlying model of TC treatment. Issues

to be investigated include: (1) staff characteristics which predict

program effectiveness; (2) essential program components that are

critical to achieve successful posttreatment outcome; (3) the

importance of TC concepts such as self-disclosure and peer role

models; and (4) client satisfaction.

Research should be undertaken to better characterize client

populations in terms of problems, needs, barriers to treatment entry

and retention, and perception of the treatment process.

Research should focus on the individual’s recovery process, both in

treatment and in the long run.

The extent to which the current, diverse array of TC-oriented

programs is guided by the perspective and purposeful use of

community as the primary method should be evaluated.

Analytic models to determine the effects of global interventions in

dynamic interaction with a changing client are needed.

Research is needed to develop and evaluate the efficacy of

assessment protocols that guide client-treatment matching strategies.

There is a corollary need to identify the relative contribution of selfselection factors to the change process.

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8. New models of addiction and recovery are required. An “ecological

dysfunction” model that views behavior (e.g., becoming addicted or

recovering) as a function of the reciprocal influence of personal and

environmental variables may be more helpful than the disease model.

9. Research on treatment of special populations is needed. While the

number of special populations is potentially large, the following are

noted as being of key interest: (1) criminal justice clients, including

prison-based programs; (2) mentally ill chemical abuser (MICA)

clients, including studies of treatment in mainstream versus

specialized TC facilities; (3) ethnic subgroups; (4) women of

childbearing age; (5) adolescents; (6) children of clients in treatment

(both those in treatment with mothers and those apart from mothers);

(7) homeless clients; and (8) human immunodeficiency virus (HIV)-

seropositive clients.

10. Research should consider the role of settings and program variations

in which TC programs are found, including prisons and jails, public

housing, hospitals, school-based programs, culture-specific locations

(e.g., Native American reservations), and the application of TC

models in day-treatment and outpatient settings.

11. Continuing studies of retention and time in treatment are needed to:

(1) clarify self-selection and program-selection issues; (2) measure

the recovery process in relation to time in treatment; (3) clarify and

measure the acculturation process in relation to retention and

recovery; (4) improve prediction of early dropout and develop

interventions to improve retention in treatment; (5) evaluate the

relationship between planned duration or recommended length of

treatment to retention in treatment; (6) determine the impact of

improved retention from the perspective of the treatment provider,

the payor, and the consumer; (7) continue to examine the relationship

of stages or levels of client motivation or coercion on retention; and

(8) assess the retention rates and outcomes of individuals with or at

high risk of HIV in TCs.

12. Studies to improve treatment process might include: (1) issues

concerning assessment and selection; (2) definition of essential

elements of TCs, their application, and their effectiveness in

particular settings; (3) innovations in treatment, for example, the

addition of relapse prevention components or inclusion of appropriate

medication protocols; (4) assessment of training in TC methods as an

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intervention to improve implementation of TC treatment and

subsequent client outcomes; and (5) assessment of how TCs can best

provide medical and other services to their HIV-infected clients and

the effects of such services on the rate of progression to AIDS and

survival.

13. To facilitate the treatment of MICA clients in TC programs, the

modality must be appropriately modified. A characterization of

psychiatric subtypes needs to be developed to distinguish individuals

according to those who are primarily drug abusers with

accompanying psychopathology from those whose primary

symptomatology is psychiatric with accompanying drug abuse. This

includes examining the association among temporal order, psychiatric

“type,” and symptom pattern (e.g., severity).

14. The significance of personality disorders in TC treatment is

recognized. The role of antisocial personality in the recovery

process, particularly the differentiation of childhood and adult

features, requires clarification.

METHODS AND STRATEGIES

1.

2.

3.

4.

5.

Match research designs and methods most appropriate to the

questions being investigated and the level of inquiry. Research

designs should be those that are capable of yielding valid findings,

and that allow appropriate choices by clients and staff. Knowledge

proceeds in stages; thus, a given design may only be appropriate after

preliminary questions have been addressed.

Review existing databases to identify opportunities for secondary

analyses and elaboration of existing knowledge.

Review program-based data archives to identify potential populations

for followup studies and opportunities to develop new databases.

Develop a national TC database that could be a major research

resource and provide a highly leveraged means of advancing

knowledge about treatment.

Provide support for training of researchers (i.e., cross-training in TC

methods) so that measurement and findings are valid.

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6.

7.

8.

9.

Provide cross-training of clinical, administrative, and research staff to

strengthen the commitment of TC programs to research and to

facilitate utilization of research findings.

Implement collaborative research projects among TCs.

Identify program-based evaluation capability in TCs as a major goal

of the TC movement. TC management should commit to routine

evaluation, development of familiar measures, and communication of

results to clinical and administrative directors and staff.

Emphasize technology transfer models to improve the application of

research findings to treatment.

RESEARCH RESOURCES

1.

2.

3.

4.

5.

Establish regional research centers for TCs similar to the Center for

Therapeutic Community Research, which was established under the

National Institute on Drug Abuse (NIDA) sponsorship following this

review. These centers should emphasize research, training, and

developing relationships with treatment programs and academic

departments.

Develop a national TC database, as described above in the Methods

and Strategies section.

Continue national conferences on TC research, either under the

auspices of NIDA or the Therapeutic Communities of America

(TCA).

Develop a structure to facilitate the dissemination of research

findings for clinical practice within the TC modality (e.g., utilization

of TCA quarterly meetings and provision of feedback mechanisms

from the clinical to the research community concerning the use of

research recommendations).

Continue to consult clinical and administrative workgroups on a

regular basis; TCA should constitute these workgroups and invite

non-TCA member participation.

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RESEARCH AND PRACTICE

While specific practice recommendations are beyond the scope of this

chapter, the recommendations for research focus, methods and strategies,

and resource development presented earlier were developed with the

intention that research address the needs of practice as well as science.

Numerous questions that directly confront those who must administer

programs and who design and deliver treatment can be systematically

addressed by research. Examples of these questions, which have been

addressed in individual chapters of this monograph, include intended

length of treatment, retention in treatment, treatment process, feedback on

treatment effectiveness, treatment of clients with co-occurring mental

disorders, treatment of women with children, treatment of clients in the

criminal justice system, and HIV-related issues.

The administration, design, and delivery of treatment can be improved by

research, but the individuals and organizations that deliver treatment

services must be partners in the enterprise. They should share in the

responsibility for: (1) helping to identify those research questions that

have both immediate, practical significance and long-term value for the

TC and other modalities; (2) developing an understanding of the

requirements for appropriately implemented research and assisting

researchers in successful implementation of projects; (3) becoming

partners with researchers in developing and implementing research

strategies, so that the validity and focus of the studies are appropriately

ensured; (4) routinizing the collaboration with researchers and the

collection of data for both studies and ongoing evaluation; and

(5) developing mechanisms for dissemination of research findings and

working with researchers to translate these findings into useful

recommendations for practice.

Some of these initiatives to link research and practice can be carried out

between programs and researchers or by researchers within programs.

On a broader scale, organizations such as TCA can do much to improve

collaborations with researchers. Finally, the TC movement should strive

to encourage research in its own community and to develop a larger cadre

of researchers trained in the TC perspective.

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AUTHORS

Frank M. Tims, Ph.D.

Chief

Treatment Services Research Branch

Division of Clinical Research

National Institute on Drug Abuse

National Institutes of Health

Parklawn Building, Room 10A5600 Fishers Lane

Rockville, MD 20857

Nancy Jainchill, Ph.D.

Senior Principal Investigator

George De Leon, Ph.D.

Director

Center for Therapeutic Community Research

National Development and Research Institutes

11 Beach Street

New York, NY 10013

286
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THE BEHAVIORAL ASPECTS OF SMOKING. Norman A.

Krasnegor, Ph.D., ed. (Reprint from 1979 Surgeon General’s

Report on Smoking and Health.)

NCADI #M26 NTIS PB #80-118755/AS (A09) $27.00

THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL

FLUIDS. Richard L. Hawks, Ph.D., ed.

NCADI #M42 NTIS PB #83-136044/AS (A07) $27.00

COCAINE: PHARMACOLOGY, EFFECTS, AND

TREATMENT OF ABUSE. John Grabowski, Ph.D., ed.

NCADI #M50 NTIS PB #85-150381/AS (A07) $27.00

TESTING DRUGS FOR PHYSICAL DEPENDENCE

POTENTIAL AND ABUSE LIABILITY. Joseph V. Brady, Ph.D.,

and Scott E. Lukas, Ph.D., eds.

NCADI #M52 NTIS PB #85-150373/AS (A08) $27.00

PHARMACOLOGICAL ADJUNCTS IN SMOKING

CESSATION. John Grabowski, Ph.D., and Sharon M. Hall, Ph.D.,

eds.

NCADI #M53 NTIS PB #89-123186/AS (A07) $27.00

MECHANISMS OF TOLERANCE AND DEPENDENCE.

Charles Wm. Sharp, Ph.D., ed.

NCADI #M54 NTIS PB #89-103279/AS (A19) $52.00

ETIOLOGY OF DRUG ABUSE: IMPLICATIONS FOR

PREVENTION. Coryl LaRue Jones, Ph.D., and Robert J. Battjes,

D.S.W., eds.

NCADI #M56 NTIS PB #89-123160/AS (A13) $36.50

COCAINE USE IN AMERICA: EPIDEMIOLOGIC AND

CLINICAL PERSPECTIVES. Nicholas J. Kozel, M.S., and Edgar

H. Adams, M.S., eds.

NCADI #M61 NTIS PB #89-131866/AS (A11) $36.50

NEUROSCIENCE METHODS IN DRUG ABUSE RESEARCH.

Roger M. Brown, Ph.D., and David P. Friedman, Ph.D., eds.

NCADI #M62 NTIS PB #89-130660/AS (A08) $27.00

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PREVENTION RESEARCH: DETERRING DRUG ABUSE

AMONG CHILDREN AND ADOLESCENTS. Catherine S. Bell,

M.S., and Robert J. Battjes, D.S.W., eds.

NCADI #M63 NTIS PB #89-103287/AS (A11) $36.50

PHENCYCLIDINE: AN UPDATE. Doris H. Clouet, Ph.D., ed.

NCADI #M64 NTIS PB #89-131858/AS (A12) $36.50

WOMEN AND DRUGS: A NEW ERA FOR RESEARCH.

Barbara A. Ray, Ph.D., and Monique C. Braude, Ph.D., eds.

NCADI #M65 NTIS PB #89-130637/AS (A06) $27.00

OPIOID PEPTIDES: MEDICINAL CHEMISTRY. Rao S.

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eds.

NCADI #M69 NTIS PB #89-158422/AS (A17) $44.50

OPIOID PEPTIDES: MOLECULAR PHARMACOLOGY,

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Richard L. Hawks, Ph.D., eds.

NCADI #M70 NTIS PB #89-158430/AS (A18) $52.00

RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M.

Tims, Ph.D., and Carl G. Leukefeld, D.S.W., eds.

NCADI #M72 NTIS PB #89-151963/AS (A09) $36.50

NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG

ABUSE. Stephen I. Szara, M.D., D.Sc., ed.

NCADI #M74 NTIS PB #89-151989/AS (A07) $27.00

THE ROLE OF NEUROPLASTICITY IN THE RESPONSE TO

DRUGS. David P. Friedman, Ph.D., and Doris H. Clouet, Ph.D.,

eds.

NCADI #M78 NTIS PB #88-245683/AS (A10) $36.50

STRUCTURE-ACTIVITY RELATIONSHIPS OF THE

CANNABINOIDS. Rao S. Rapaka, Ph.D., and Alexandros

Makriyannis, Ph.D., eds.

NCADI #M79 NTIS PB #89-109201/AS (A10) $36.50

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NEEDLE SHARING AMONG INTRAVENOUS DRUG

ABUSERS: NATIONAL AND INTERNATIONAL

PERSPECTIVES. Robert J. Battjes, D.S.W., and Roy W. Pickens,

Ph.D., eds.

NCADI #M80 NTIS PB #88-236138/AS (A09) $36.50

OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty,

Ph.D., and David P. Friedman, Ph.D., eds.

NCADI #M82 NTIS PB #88-245691/AS (A06) $27.00

HEALTH HAZARDS OF NITRITE INHALANTS. Harry W.

Haverkos, M.D., and John A. Dougherty, Ph.D., eds.

NCADI #M83 NTIS PB #89-125496/AS (A06) $27.00

LEARNING FACTORS IN SUBSTANCE ABUSE. Barbara A.

Ray, Ph.D., ed.

NCADI #M84 NTIS PB #89-125504/AS (A10) $36.50

EPIDEMIOLOGY OF INHALANT ABUSE: AN UPDATE.

Raquel A. Crider, Ph.D., and Beatrice A. Rouse, Ph.D., eds.

NCADI #M85 NTIS PB #89-123178/AS (A10) $36.50

OPIOID PEPTIDES: AN UPDATE. Rao S. Rapaka, Ph.D., and

Bhola N. Dhawan, M.D., eds.

NCADI #M87 NTIS PB #89-158430/AS (A11) $36.50

MECHANISMS OF COCAINE ABUSE AND TOXICITY. Doris

H. Clouet, Ph.D.; Khursheed Asghar, Ph.D.; and Roger M. Brown,

Ph.D., eds.

NCADI #M88 NTIS PB #89-125512/AS (A16) $44.50

BIOLOGICAL VULNERABILITY TO DRUG ABUSE. Roy W.

Pickens, Ph.D., and Dace S. Svikis, B.A., eds.

NCADI #M89 NTIS PB #89-125520/AS (A09) $27.00

TESTING FOR ABUSE LIABILITY OF DRUGS IN HUMANS.

Marian W. Fischman, Ph.D., and Nancy K. Mello, Ph.D., eds.

NCADI #M92 NTIS PB #90-148933/AS (A17) $44.50

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PHARMACOLOGY AND TOXICOLOGY OF AMPHETAMINE

AND RELATED DESIGNER DRUGS. Khursheed Asghar, Ph.D.,

and Errol De Souza, Ph.D., eds.

NCADI #M94 NTIS PB #90-148958/AS (A16) $44.50

PROBLEMS OF DRUG DEPENDENCE, 1989. PROCEEDINGS

OF THE 51st ANNUAL SCIENTIFIC MEETING. THE

COMMITTEE ON PROBLEMS OF DRUG DEPENDENCE, INC.

Louis S. Harris, Ph.D., ed.

NCADI #M95 NTIS PB #90-237660/AS (A99) $67.00

DRUGS OF ABUSE: CHEMISTRY, PHARMACOLOGY,

IMMUNOLOGY, AND AIDS. Phuong Thi Kim Pham, Ph.D., and

Kenner Rice, Ph.D., eds.

NCADI #M96 NTIS PB #90-237678/AS (A11) $36.50

NEUROBIOLOGY OF DRUG ABUSE: LEARNING AND

MEMORY. Lynda Erinoff, Ph.D., ed.

NCADI #M97 NTIS PB #90-237686/AS (A11) $36.50

THE COLLECTION AND INTERPRETATION OF DATA

FROM HIDDEN POPULATIONS. Elizabeth Y. Lambert, M.S.,

ed.

NCADI #M98 NTIS PB #90-237694/AS (A08) $27.00

RESEARCH FINDINGS ON SMOKING OF ABUSED

SUBSTANCES. C. Nora Chiang, Ph.D., and Richard L. Hawks,

Ph.D., eds.

NCADI #M99 NTIS PB #91-141119 (A09) $27.00

DRUGS IN THE WORKPLACE: RESEARCH AND

EVALUATION DATA. VOL II. Steven W. Gust, Ph.D.;

J. Michael Walsh, Ph.D.; Linda B. Thomas, B.S.; and Dennis J.

Crouch, M.B.A., eds.

NCADI #M100 GPO Stock #017-024-01458-3 $8.00

RESIDUAL EFFECTS OF ABUSED DRUGS ON BEHAVIOR.

John W. Spencer, Ph.D., and John J. Boren, Ph.D., eds.

NCADI #M101 NTIS PB #91-172858/AS (A09) $27.00

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102 ANABOLIC STEROID ABUSE. Geraline C. Lin, Ph.D., and

Lynda Erinoff, Ph.D., eds.

NCADI #M102 NTIS PB #91-172866/AS (A11) $36.50

106 IMPROVING DRUG ABUSE TREATMENT. Roy W. Pickens,

Ph.D.; Carl G. Leukefeld, D.S.W.; and Charles R. Schuster, Ph.D.,

eds.

NCADI #M106 NTIS PB #92-105873 (A18) $50.00

107 DRUG ABUSE PREVENTION INTERVENTION RESEARCH:

METHODOLOGICAL ISSUES. Carl G. Leukefeld, D.S.W., and

William J. Bukoski, Ph.D., eds.

NCADI #M107 NTIS PB #92-160985 (A13) $36.50

108 CARDIOVASCULAR TOXICITY OF COCAINE:

UNDERLYING MECHANISMS. Pushpa V. Thadani, Ph.D., ed.

NCADI #M108 NTIS PB #92-106608 (A11) $36.50

109 LONGITUDINAL STUDIES OF HIV INFECTION IN

INTRAVENOUS DRUG USERS: METHODOLOGICAL ISSUES

IN NATURAL HISTORY RESEARCH. Peter Hartsock, Dr.P.H.,

and Sander G. Genser, M.D., M.P.H., eds.

NCADI #M109 NTIS PB #92-106616 (A08) $27.00

111 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH:

RECEPTOR CLONING, NEUROTRANSMITTER

EXPRESSION, AND MOLECULAR GENETICS: VOLUME I.

Theresa N.H. Lee, Ph.D., ed.

NCADI #M111 NTIS PB #92-135743 (A10) $36.50

112 EMERGING TECHNOLOGIES AND NEW DIRECTIONS IN

DRUG ABUSE RESEARCH. Rao S. Rapaka, Ph.D.; Alexandros

Makriyannis, Ph.D.; and Michael J. Kuhar, Ph.D., eds.

NCADI #M112 NTIS PB #92-155449 (A15) $44.50

113 ECONOMIC COSTS, COST EFFECTIVENESS, FINANCING,

AND COMMUNITY-BASED DRUG TREATMENT. William S.

Cartwright, Ph.D., and James M. Kaple, Ph.D., eds.

NCADI #M113 NTIS PB #92-155795 (A10) $36.50

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METHODOLOGICAL ISSUES IN CONTROLLED STUDIES

ON EFFECTS OF PRENATAL EXPOSURE TO DRUG ABUSE.

M. Marlyne Kilbey, Ph.D., and Khursheed Asghar, Ph.D., eds.

NCADI #M114 NTIS PB #92-146216 (A16) $44.50

METHAMPHETAMINE ABUSE: EPIDEMIOLOGIC ISSUES

AND IMPLICATIONS. Marissa A. Miller, D.V.M., M.P.H., and

Nicholas J. Kozel, M.S., eds.

NCADI #M115 NTIS PB #92-146224/11 (A07) $27.00

DRUG DISCRIMINATION: APPLICATIONS TO DRUG

ABUSE RESEARCH. R.A. Glennon, Ph.D.; Toubjörn U.C. Järbe,

Ph.D.; and J. Frankenheim, Ph.D., eds.

NCADI #M116 NTIS PB #94-169471 (A20) $52.00

METHODOLOGICAL ISSUES IN EPIDEMIOLOGY,

PREVENTION, AND TREATMENT RESEARCH ON DRUGEXPOSED WOMEN AND THEIR CHILDREN. M. Marlyve

Kilbey, Ph.D., and Kursheed Asghar, Ph.D., eds.

NCADI #M117

GPO Stock #017-024-01472-9 $12.00

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DRUG ABUSE TREATMENT IN PRISONS AND JAILS. Carl

G. Leukefeld, D.S.W., and Frank M. Tims, Ph.D., eds.

GPO Stock #017-024-01473-7 $16.00

NCADI #M118 NTIS PB #/93-102143/LL (A14) $44.50

BIOAVAILABILITY OF DRUGS TO THE BRAIN AND THE

BLOOD-BRAIN BARRIER. Jerry Frankenheim, Ph.D., and

Roger M. Brown, Ph.D., eds.

NCADI #M120

GPO Stock #017-024-01481-8 $10.00

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BUPRENORPHINE: AN ALTERNATIVE TREATMENT FOR

OPIOID DEPENDENCE. Jack D. Blaine, Ph.D., ed.

GPO Stock #017-024-01482-6 $5.00

NCADI #M121 NTIS PB #93-129781/LL (A08) $27.00

ACUTE COCAINE INTOXICATION: CURRENT METHODS

OF TREATMENT. Heinz Sorer, Ph.D., ed.

GPO Stock #017-024-01501-6 $6.50

NCADI #M123 NTIS PB #94-115433/LL (A09) $27.00

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124 NEUROBIOLOGICAL APPROACHES TO BRAIN-BEHAVIOR

INTERACTION. Roger M. Brown, Ph.D., and Joseph Fracella,

Ph.D., eds.

NCADI #M124

GPO Stock #017-024-01492-3 $9.00

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125 ACTIVATION OF IMMEDIATE EARLY GENES BY DRUGS

OF ABUSE. Reinhard Grzanna, Ph.D., and Roger M. Brown,

Ph.D., eds.

NCADI #M125

GPO Stock #017-024-01503-2 $7.50

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126 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH

VOLUME II: STRUCTURE, FUNCTION, AND EXPRESSION.

Theresa N.H. Lee, Ph.D., ed.

NCADI #M126 NTIS PB #94-169497 (A08) $27.00

127 PROGRESS AND ISSUES IN CASE MANAGEMENT. Rebecca

Sager Ashery, D.S.W., ed.

NCADI #M127 NTIS PB #94-169505 (A18) $52.00

128 STATISTICAL ISSUES IN CLINICAL TRIALS FOR

TREATMENT OF OPIATE DEPENDENCE. Ram B. Jain, Ph.D.,

ed.

NCADI #M128 NTIS PB #93-203826/LL (A09) $27.00

129 INHALANT ABUSE: A VOLATILE RESEARCH AGENDA.

Charles W. Sharp, Ph.D.; Fred Beauvais, Ph.D., and Richard

Spence, Ph.D., eds.

NCADI #M129

GPO Stock #017-024-01496-6 $12.00

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130 DRUG ABUSE AMONG MINORITY YOUTH: ADVANCES IN

RESEARCH AND METHODOLOGY. Mario De La Rosa, Ph.D.,

and Juan-Luis Recio Adrados, Ph.D., eds.

GPO Stock #017-024-01506-7 $14.00

NCADI #M130 NTIS PB #94-169513 (A15) $44.50

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131 IMPACT OF PRESCRIPTION DRUG DIVERSION CONTROL

SYSTEMS ON MEDICAL PRACTICE AND PATIENT CARE.

James R. Cooper, Ph.D.; Dorynne J. Czechowicz, M.D.; Stephen P.

Molinari, J.D., R.Ph.; and Robert C. Peterson, Ph.D., eds.

GPO Stock #017-024-01505-9 $14.00

NCADI #M131 NTIS PB #94-169521 (A15) $44.50

132 PROBLEMS OF DRUG DEPENDENCE, 1992: PROCEEDINGS

OF THE 54TH ANNUAL SCIENTIFIC MEETING OF THE

COLLEGE ON PROBLEMS OF DRUG DEPENDENCE. Louis

Harris, Ph.D., ed.

NCADI #M132

GPO Stock #017-024-01502-4 $23.00

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133 SIGMA, PCP, AND NMDA RECEPTORS. Errol B. De Souza,

Ph.D.; Doris Clouet, Ph.D., and Edythe D. London, Ph.D., eds.

NCADI #M133 NTIS PB #94-169539 (A12) $36.50

134 MEDICATIONS DEVELOPMENT: DRUG DISCOVERY,

DATABASES, AND COMPUTER-AIDED DRUG DESIGN. Rao

S. Rapaka, Ph.D., and Richard L. Hawks, Ph.D., eds.

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NCADI #M134 NTIS PB #94-169547 (A14) $44.50

135 COCAINE TREATMENT: RESEARCH AND CLINICAL

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D.S.W., eds.

NCADI #M135

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136 ASSESSING NEUROTOXICITY OF DRUGS OF ABUSE.

Lynda Erinoff, Ph.D., ed.

NCADI #M136

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137 BEHAVIORAL TREATMENTS FOR DRUG ABUSE AND

DEPENDENCE. Lisa Simon Onken, Ph.D.; Jack D. Blaine, M.D.,

and John J. Boren, Ph.D., eds.

NCADI #M137

GPO Stock #017-024-01519-9 $13.00

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138 IMAGING TECHNIQUES IN MEDICATIONS

DEVELOPMENT: CLINICAL AND PRECLINICAL ASPECTS.

Heinz Sorer, Ph.D., and Rao S. Rapaka, Ph.D., eds.

NCADI #M138

139 SCIENTIFIC METHODS FOR PREVENTION INTERVENTION

RESEARCH. Arturo Cazares, M.D., M.P.H., and Lula A. Beatty,

Ph.D., eds.

NCADI #M139

140 PROBLEMS OF DRUG DEPENDENCE, 1993: PROCEEDINGS

OF THE 55TH ANNUAL SCIENTIFIC MEETING, THE

COLLEGE ON PROBLEMS OF DRUG DEPENDENCE, INC.

VOLUME I: PLENARY SESSION SYMPOSIA AND ANNUAL

REPORTS. Louis S. Harris, Ph.D., ed.

NCADI #M140

141 PROBLEMS OF DRUG DEPENDENCE, 1993: PROCEEDINGS

OF THE 55TH ANNUAL SCIENTIFIC MEETING, THE

COLLEGE ON PROBLEMS OF DRUG DEPENDENCE, INC.

VOLUME II: ABSTRACTS. Louis S. Harris, Ph.D., ed.

NCADI #M141

142 ADVANCES IN DATA ANALYSIS FOR PREVENTION

INTERVENTION RESEARCH. Linda M. Collins, Ph.D., and

Larry A. Seitz, Ph.D., eds.

143 THE CONTEXT OF HIV RISK AMONG DRUG USERS AND

THEIR SEXUAL PARTNERS. Robert J. Battjes, D.S.W.; Zili

Sloboda, Sc.D.; and William C. Grace, Ph.D., eds.

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NIH Publication No. 94-3633

Printed 1994