Monthly Archives: March 2014

Effectiveness of Therapeutic Communities in Drug Treatment


In a January 2014 issue of the Journal of Child and Adolescent Substance Abuse, within an article entitled “Therapeutic Engagement as a Predictor of Retention in Adolescent Therapeutic Community treatment,” authors offer that Therapeutic Communities (TCs) are effective in so far as they lead to reduced substance use along with reductions of other types of delinquent behavior. This isn’t a new assertion, nor is the apologist follow-up that much is still unknown in terms of what factors increase the likelihood that an adolescent will remain, much less thrive in treatment. Strange, since the Therapeutic Community model has been around for just over fifty years, ever since Synanon was founded in the late fifties to address problems of addiction. One might think that fifty years was enough time to give the Therapeutic Community model some scrutiny, some thought, and to determine what aspects of this somewhat controversial model work, and what aspects don’t. Well, it isn’t strange to me. Actually, when I consider all the elements of such a model (drawn from my fifteen years working within such programs), I try to imagine how a truly comprehensive research study might control for all factors. Therefore, it’s not surprising to me that the consumer of services is left reading research platitudes that beg a plethora of further questions.

            The efficacy of the Therapeutic Community model is one of several subjects I tackle in my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment. For those unfamiliar with the TC model, it is described by one notable researcher as the following: a total milieu treatment (as in residential) that promotes positive peer culture and socialization, with confrontation as a staple technique of the TC approach. How does that sound? If it sounds good so far, then okay. But if you’re reading from the point of view of somehow who might soon be living in a TC, or from the POV of a parent wondering whether to place your son or daughter in a TC, you’ll likely want to know more. You might take a look at literature on TCs that came out of Australia in 2010, though researchers Foster, Nathan, Ferry are similarly cautious about what is truly effective in therapeutic communities. Alternatively, you might want to tour such a place, take a moment to sit in one of its dorm-style bedrooms, and take in the atmosphere, the buzz. I remember the first time I toured a TC as a would-be employee. It was Thunder Road near downtown Oakland, and it was the mid-nineties. I took in the harsh noise of the unit that first day, as well as its tense silences. The atmosphere was one of anxiety, the restlessness of kids addicted to drugs, risk taking in general; the barely suppressed rage borne of thwarted freedoms and deeply-rooted yet thinly acknowledged pain. Through my book, I give readers a first-hand feel of how a typical TC operates. I’ll sit you upon its time-out devices, the bench, and have you gaze into its affirmation mirrors. I’ll give you a pair of hospital scrubs and strip you of your clothes and other belongings. Before long you’ll be sitting in confrontation group, or in something called contract breaking. Later, you’ll be doing some chores to keep you and your living environment both literally and figuratively clean. Then you’ll go to a 12-step meeting, and after that, maybe a family therapy session. You’ll learn that these norms, methods, and that the principles that underlie them follow a rigorous structure, and have a long pedigree.

            If you read studies about treatment models, you’ll likely come across terms like “completion rates” or “retention”. Within the literature pertaining to efficacy of programs, concepts like completion or retention are deemed tantamount to successful engagement of patients. If you complete a treatment of, say, 4-6 weeks (or longer), versus dropping out of treatment, then the treatment episode is implicitly effective, and a program looking to promote its services might refer to completion rates as indicators of success. Alternatively, programs might refer to studies (across programs) that demonstrate the efficacy of TCs in reducing substance use, though you might wonder about the methods of research. For example, if a person is said to be clean from substances post-treatment, how exactly is this determined? Is it through mandated submission to urinalysis testing? Or, are questionnaires being used: self-report essentially, from adolescents or their parental co-participants? Also, how long after treatment are the determinations being made? Are questionnaires being administered within 72 hours of discharge? Ninety days? Six months? I recall conducting post-discharge surveys for three different programs over the course of my fifteen years. The average length of time passed before conducting the surveys was about six weeks.

            Imagine your information is used for such a study (not that your name would be revealed). Think what it would be like for you if your treatment program was deemed successful because people like you completed the required number of days, or because you volunteered that you were still clean after eighty nine days. And even if that’s true, what if you relapsed on day ninety two? A program might benefit from the statistics, but what consolation would this be to those who slip back into old habits, and perhaps worsen from a previous baseline of addictive behavior? Many who go through drug treatment do so on multiple occasions, at great personal as well as societal cost. In future articles, I will address the problem of repeat customers in treatment, and argue for practices that aim for long-term change versus band-aid solutions and a low-bar, common denominator of treatment success. Long term, as in sustained change is what the consumer of drug treatment wants, after all. And it will take hard work, not to mention patience if treatment programs are to meet these standards. Studies of treatment efficacy that track change over time are few and—of course—far between. Exhibiting a quality that is perceived in most addicts, consumers of drug treatment research follow an ironic yet understandably urgent pursuit. They want the immediate gratification of fresh information, the latest studies. They cannot wait.


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Exiting The Schizoid Program

Charlie Z., Candace Orcutt’s next case study from Trauma In Personality Disorder, seems at first to be living the life that schizoid personalities might envy: he lives alone, works with technology, and does not appear to have authority figures hovering over him. Then one day an intruder breaks into his apartment, pistol-whips him, and locks him in a closet, which later triggers associations with a childhood memory of being locked in a closet by his father as a punishment. The latter day incident immobilizes Mr. Z. His apartment, previously a haven, becomes as much a source of danger as the outside world. Sleep disturbance and panic symptoms follow; Mr. Z seeks medication, tries to use his intellect to reason through his fears. One foot in, one foot out, Mr. Z metaphorically and literally lives the schizoid dilemma in his apartment.

            In therapy it seems more or less the same: he reports feelings, says he’s in pain, but superficially describes the break-in event, and moves away from his feelings with plaintive questions, acting out in the form of lateness and canceled sessions. Candace delivers now familiar interventions: she assures him that memories fade, educates that his dizziness constitutes “remembering in the now”. Therapy eases his symptoms somewhat, but Mr. Z calls a halt to the sessions. Candace agrees, meaning she works with the disorder rather than resolving it. Nicely put, I thought, though I am once again struck by the way her cases stop and start.  

            Some time later Mr. Z. returns for therapy, ostensibly because his anxiety symptoms have returned, and Candace speculates that a new relationship with a female friend is the cause. This time Candace learns more about Mr. Z’s life, about his freelance work, his hobbies (science fiction—big surprise), and somewhat fastidious personal routine. She inquires after his new relationship, which is introduced first as a correspondence, but later graduates to a physical meeting, with all the attendant threats of closeness and sex. I like the way Candace uses Mr. Z’s comfort with computers as a bridge to negotiating a safe relationship. Actions can be taken but then undone; one can hit “escape” or exit a program, she reframes. This leads to further process about closeness, and Candace continues with interpretations of schizoid dilemmas. Eventually we learn more about Mr. Z’s childhood, about his being bullied into self-sufficiency by a rigid, perfectionist father and a passively cooperative mother. He resolves to think of them as cruel, and Candace offers speculations as to their own abuse history. I’m not sure what to write of these interventions, but was disappointed to learn that Mr. Z chose again to stop treatment. He reminds me of a Kafkaesque character transformed by his closeted life into some manner of human/rodent hybrid that’s ever hiding in the dark.






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The Careless Passage of Time


In the next section of Candace Orcutt’s book, Trauma in Personality Disorder, we read of Mr. H. and Mrs. M. Mr. H., she describes, presents a case with “traumatic overtones”, though the trauma isn’t obvious at first. Is it the rejection from his wife? The business failure, coupled with the partner’s nefarious financial actions? The problems with his adult children? He is depressed, Narcissistic, manifestly so (exhibitionistic?), and according to Orcutt, needful of mirroring, and not always with an accompanying interpretation. The Narcissist has an antipathy towards interpretation, she writes (p. 100), but she points out that the Masterson model bypasses this antipathy by wrapping such interventions with empathy for the patient’s vulnerability. With that seeming understanding in mind, one wonders why her transcripts appear to wander so often from the technique: instances of reassurance (p. 97: “it will get better in the end”, p. 91: “you have your kids and your pride. You’re managing”); so-called reasoning (p. 88: “Wouldn’t it be easier to stop fighting and accept the offer?”); a warning (p. 86: “Maybe it’s important to remember that reaction plays into others’ hands”); a confrontation (p. 85: “are you really defending yourself by turning this into WWIII”). The mirroring aims at maintaining idealized unity with the therapist; the confrontation a containment of acting out; the reassurance perhaps girds Mr. H. for his subsequent disclosures about an incestuous relationship with his mother. He ends therapy having broken a secret, and seems happy enough, with a new woman in his life and a better relationship with his kids. 

Orcutt writes that mirroring alone may be necessary when the patient is feeling especially vulnerable. This feels very permitting somehow, as though the interpretive piece were an extra chore for both patient and therapist; both are spared the task of dealing with the question of criticism that ambiguously lies within mirroring interpretations. Mrs. M is stoical, likes to “fix” problems. She seeks to control feelings, often by dismissing them, and thinks that having feelings and acting upon them are conflated concepts. She also discovers a family secret, through the experience of an accident in which no was injured, though Mrs. M. begins to suffer symptoms of PTSD. She wants medication, and hypnosis; she doesn’t want to dwell. She resists the psychologizing of her reaction from doctors, but soon integrates the therapeutic suggestion that her symptoms derive from stress, and more importantly, she acknowledges helplessness with respect to her fears. This appears to open up memories, including an incident in her teens wherein she felt responsible for a friend’s accident. Symptoms persist, and the therapist gives homework for Mrs. M. to interview family members about recurrent dreams of a little girl being killed. The investigation unearths a horrific family secret: a tragic incident in which Mrs. M’s four year old twin sister is accidentally killed by her mother’s first husband. Mrs. M. had witnessed the scene, but was thereafter amnestic, and the mother resolved to not talk about it. This is a painful story, one that had me reflecting sympathetically upon the father of the deceased girl as much as the horror of Mrs. M. She is distraught by the discovery, and blames the therapist for not preparing her for the burdens of memory. The therapist reassures that life will be put back “into one piece”, and adds that perhaps time will bring a change. Cliches aside, attributing change to the passage of time seems incomplete, even careless.


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