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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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Working Through Rehab: Growing out of it


In Masterson’s The Psychiatric Dilemma of Adolescence, published in 1967, the problem of treating kids in the psychiatric setting is exhaustively examined. Noting the tendency of clinicians to dismiss diagnoses of clients, saying “he or she will grow out of it”, in reference to a plethora of acting out and mental health problems. Meanwhile, Masterson recounts that social scientists in the 60s were attempting to organize the phenomena they studied, rather like researchers of the physical sciences, and thus methodology changed; so-called objective research, focusing upon variables like validity, reliability, and statistical analyses, were coming to the fore and changing the ways clinicians addressed problems. Masterson, however, grew conflicted about the differences between the social science methodological point of view, and his and others’ clinical observations.

Masterson found after his twelve year study, that 50% of the adolescents he studied did not “grow out of problems” upon five year follow-ups, and that while symptoms like anxiety, depression, and acting out (with sex, drugs, or violence) did diminish, but that which brought the most difficulty, in terms of sustaining meaningful relationships, activating healthy goals, ambitions, accessing creativity and self-care–their pathological character traits–had not been touched upon in treatment…at all.

As much as anything, my reflections in Working Through Rehab: An Inside Look at Adolescent Drug Treatment, are derived from Masterson’s implied warnings about the costs of a superficial treatment approach. I recall working with a young lady in my private practice–a late teen–who was supposedly drawn to relationships with boys “from the wrong side of the tracks”. Much thought, encouragement, argument, and time had been put into making her see reason, re-think her “choices”, and make “rational” decisions. The cognitive dissonance was pervasive: she wanted safety and “respect”, but was drawn to men inclined to hurt her. She wanted independence, but ended up feeling anything but. She was drawn to the bohemian, the pull of rebellion, and found separation in rejection of her family’s fears. Little did she know how conflicted she was with herself, not others, and how long the conflict would last if she did nothing about it. In my first novel, Living Without Blood, I presented the consequences for a family living by the rule, “time heals all wounds”. The Metcalfs  discover that time passage without conscious intrusion does little more than fossilize understandings, generating alienation.

In Working Through Rehab, I depict therapeutic environments that are either forgetting, actively disregarding, or plainly ignorant of Masterson’s now forty year old caveats. Programs working with kids are operating upon the assumption, “they’ll grow out of it”, seeking to emphasize kids’ positive traits in the hope that their deficits will fall away under the power of love. Or, they’ve taken a subtly defeatist tact, thinking the wounds are too great, the fossilization too hard and too widespread, such that the roots of problems are impenetrable.

Do you think this, my would-be reader? Are you a mental health practitioner? A consumer of services. Who are you that you might be interested in this topic? Who do you need to be? Who am I to make pronouncements on trends that flit in and out of fashion, some sticking, some not. Who do I need to be?



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August 13, 2013 · 8:57 pm

Working In Rehab: a numbers game

Check this out: Do you like numbers? Ok, here’s a few statistics: according to the Treatment Episode Data Set (TEDS) report, as published online by the Substance Abuse and Mental Health Services Administration (SAMHSA), almost 2 million people were admitted for substance abuse treatment in 2010 across the United States, and just over 2 million people were admitted for the same problem in 2009. These are the most recent years for which such statistics exist. The average number treated over the five years prior to this was between 1.8 and 1.9 million people per year, admitted to just over 13,000 facilities licensed or certified to treat individuals for substance abuse. According to the same data tables, between 7 and 8 percent of these admissions—again, on average—are kids. By kids, I mean ages 12-17, and most of these kids are between 15 and 17. That’s about 150,000 teens per year entering programs, in outpatient or inpatient settings—rehab, as the shorthand goes—for the treatment of substance abuse. And by the way, substance abuse is only one of many problems these kids have. This is the kind of information you’ll find in my forthcoming book about drug rehab and teens, due out soon–though, don’t be misled: my book won’t be dominated by numbers. In fact, you’ll see (I hope) that it takes a skeptical view in general of the application of numbers to my profession.

You see, my profession, that of a therapist, is about making a personal connection with people. I know that sounds like sanguine bullshit, but unlike the average entrepreneur, I’m not selling a product alongside a transient interaction that purports to represent commitment. I’m talking about a solid idea that’s quietly being marginalized in the business of mental health services: it’s the relationship(s) that heal. Not so, according to the larger systems in charge: hospitals, insurance companies; managed care. For them, it’s about “quantifiable” aims, that which can be tracked in terms of symptoms, so-called “scales”, tests of one sort or another. Go to a program, especially a hospital based program and you’ll hear the mantra: tests, tests, we must do tests. Later there will be estimates, both of prognosis, and of the money involved. It’s a reductionist process. Why? Because those paying say so, that’s why. They’ve even enlisted scientists to this cause. By scientists I mean researchers of mental health, people scrambling to publish studies whose findings will rubber stamp the proposed treatment approaches. The process here is tautological: find that which confirms efficacy of the pre-ordained standards. Make it understood that the most cost-effective approaches are the best. Proselytize use of those models that are the easiest to train to the growing numbers of fledgling professionals who are eager for jobs and at best secondarily concerned as to what they’re teaching.

How do I know people like me are looking for jobs? If you don’t believe me, believe a ph.d. Hey, that rhymes. In a report for the California department of Mental Health in 2009, John Shea indicated that positions for social workers, marriage and family therapists, and other counselors would grow by 22%, 21%, and 33% respectively (projected until 2016). His report indicated that over 22,000 people held MFT licenses at that time. That number now stands at over 33,000 according to department statistics. Whoa, that’s growth for you. I wonder if the jobs will run out. At what point does the Board of Behavioral Sciences start making its licensing exams harder to pass, thus titrating the numbers coming into the field. There. That’s a token for those who may wonder who I am to say what’s happening in the business of drug treatment. My question back: who do I need to be?

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