Exploring the "black-box" of therapeutic community (TC) methodology and the subjective experiences of residents within TC structures

Citation

Aslan, L. and Yates, R. (2015), "Exploring the "black-box" of therapeutic community (TC) methodology and the subjective experiences of residents within TC structures", Therapeutic Communities: The International Journal of Therapeutic Communities, Vol. 36 No. 2. https://doi.org/10.1108/TC-04-2015-0014

Exploring the "black-box" of therapeutic community (TC) methodology and the subjective experiences of residents within TC structures

Article Type: Guest editorial From: Therapeutic Communities: The International Journal of Therapeutic Communities, Volume 36, Issue 2.

Numerous authors (De Leon, 2000; De Leon, 2010; Yates, 2014) have argued that the long-running debates around the effectiveness of drug-free therapeutic communities (TCs) – and the ever-growing body of scientific research that this has engendered – has proved a distraction from the real question of how and why TC methodology works. Others, such as Wexler and Prendergast (2010) and Yates (2014) have argued that the framing of TC methodology within a health intervention paradigm crucially ignores the essentially educative basis of the approach. This is a vitally important distinction. Research within education is generally focused upon how well and in what way educative interventions are delivered rather than challenging the value of education per se. By framing the TC as a type of special hospital, we leave ourselves struggling to apply health-oriented research approaches (perfectly appropriate to measure the impact – or non-impact – of introducing a medication or surgical procedure compared to non-treatment) to a complex intervention where not only the individual elements but the interplay of those elements are crucial to the value delivered.

Thus this preoccupation with outcomes (normally measured in reductions in drug consumption or offending, neither of which are or should be the primary focus of a TC programme) has undermined the capacity to undertake research which can examine the actual process. Put simply, we know from 50 years of outcome studies in the field that TCs positively impact upon the lives of those who take up membership in a TC (De Leon, 2010) and we know that the TC is an extraordinarily complex intervention (De Leon, 2000; Yates, 2011) that does not readily lend itself to randomised control trial approaches. What we do not know is the relative importance of the component parts of the TC approach: how they work, how they interact with other elements, whether (and in what way) we could adjust them to make them work better and how clients experience them.

We have dedicated this issue to David Turner, a pioneer and champion of the humanistic principles of the TC. David will be remembered for his powerful advocacy of the service user and thus, it is entirely appropriate that this issue is, in the main, an attempt to understand the impact of the TC upon those who experience it. The majority of the papers contained in this issue explore the nature of the client group and the impact upon them of their residence within/attendance at, a TC programme.

It is now acknowledged that the populations seen in TCs will tend to be more damaged and to have experienced more lifestyle chaos than those in other types of treatment intervention; particularly those treated in non-residential settings (Yates, 2008; Pitts and Yates, 2010; Sacks and Sacks, 2010; Freestone and Goodman, 2009). The paper by Henriques and Candeias explores the nature of the drug users’ existence one year after their immersion within the TC. The following paper by Vandevelde, De Maeyer, De Ruysscher, Bryssinck, Meesen, Vanderstraeten and Broekaert examines the experiences of service users with co-existing mental health issues and the importance of creating a welcoming and crucially, safe space for them.

The past two decades have seen a relentless pressure upon TCs to shorten the duration of treatment with little evidence of a reduction in outcome expectations. However, TCs have generally risen to this challenge: in particular by increasing retention and improving after-care arrangements. Moreover, whilst treatment duration remains an important indicator of treatment outcome, it has become clear that treatment engagement is an equally important predictor of change (Joe et al., 1999; Yates, 2010). The paper by Aslan breaks relatively new ground by exploring the experiences of a small number of TC “drop-outs” to measure whether their time in treatment – despite early termination – had resulted in any drug-use or lifestyle changes. Interestingly, this small study suggests that even a limited exposure to a TC environment may have significant positive effects: a finding which surely warrants a more extensive study.

The paper by Goethals, Vanderplasschen, Vandevelde and Broekaert similarly explores the perceptions of TC residents of the TC approach and its impact at early and later stages in the process. Again the findings suggest that the impact can be profound. This paper additionally examines the changes made to this American model on its emergence within Europe and the continued modification of the approach in the years since. Similarly, Broekaert, Berg-Sørensen, Vanderplasschen and Vandevelde’s paper in this issue provides us with a historical opinion piece based around the Opbygningsgarden TC in Denmark. The piece reviews the trends and challenges faced by European TCs from their early beginnings. The following paper by Harris narrows this focus to consider the issues involved in integrating a particular new approach – in this instance, Mindfulness – into the complex intervention we describe as TC. As with other papers in this issue, this paper particularly explores the views and perceptions of the TC members.

This exploration of the introduction of new approaches into the TC framework is a critical issue. De Leon (2000, 2010) and Wexler and Prendergast (2010) have argued that there are continuing issues surrounding the erosion of TC programme fidelity and it is therefore vital that we learn more about how TCs work in order to approach their modification armed with an evidence-based understanding of what can be appropriately added without undermining the central integrity of the approach. An enduring example of this issue is the relationship between TCs and the 12-step mutual aid movement (Alcoholics Anonymous, Narcotics Anonymous, etc.).

With the increasing fiscal pressure on treatment programme duration, TCs have come more and more to rely upon a partnership with this movement to deliver enhanced after-care support. Whilst this largely works well, there is a danger that the fundamental differences between the two approaches will undermine the continuance of the TC model and confuse the TC resident. The final paper in this issue by McPhee and Fenton reports upon a small study undertaken within a modified TC to map the experiences of methadone using residents – and understanding of the recovery journey. As with many modified TCs, the line between the two philosophies can appear blurred. The study highlights how residential care and respite are required to address long-term substance abuse through adopting recovery norms – language and behaviours. The study, however, raises questions as to how residents on methadone might adopt recovery norms that are ultimately associated with abstinence.

Laura Aslan and Rowdy Yates

Laura Aslan is a Researcher at Quality and Performance, Phoenix Futures, Birkenhead, Wirral, United Kingdom. Dr Rowdy Yates is a Senior Research Fellow at School of Applied Social Science, University of Stirling, Stirling, Scotland, United Kingdom.

References

De Leon, G. (2000), The Therapeutic Community: Theory, Model and Method, Springer Publishing Company, New York, NY

De Leon, G. (2010), “Is the therapeutic community an evidence-based treatment? What the evidence says”, International Journal of Therapeutic Communities, Vol. 32 No. 2, pp. 104-128

Freestone, M. and Goodman, P. (2009), “Mental health and engagement outcomes for a UK addiction TC: the ley community”, International Journal of Therapeutic Communities, Vol. 30 No. 1, pp. 35-42

Joe, G.W., Simpson, D.D. and Broome, K.M. (1999), “Retention and patient engagement models for different treatment modalities in DATOS”, Drug and Alcohol Dependence, Vol. 57 No. 2, pp. 113-125

Pitts, J. and Yates, R. (2010), “Cost benefits of therapeutic community programming: results of an updated survey”, International Journal of Therapeutic Communities, Vol. 31 No. 2, pp. 129-144

Sacks, S. and Sacks, J. (2010), “Research on effectiveness of the modified therapeutic community for persons with co-occurring substance use and mental disorders”, International Journal of Therapeutic Communities, Vol. 31 No. 2, pp. 176-211

Wexler, H. and Prendergast, M. (2010), “Therapeutic communities in United States prisons”, International Journal of Therapeutic Communities, Vol. 32 No. 2, pp. 157-175

Yates, R. (2008), “Different strokes for different folks: results of a small study comparing characteristics of a therapeutic community population with a community drug project population”, International Journal of Therapeutic Communities, Vol. 29 No. 1, pp. 44-56

Yates, R. (2010), “Recovery we can afford: an analysis of a sample of comparative costbased studies”, International Journal of Therapeutic Communities, Vol. 31 No. 2, pp. 145-156

Yates, R. (2011), “Therapeutic communities: can-do attitudes for must-have recovery”, Journal of Groups in Addiction and Recovery, Vol. 6 No. 1, pp. 100-120

Yates, R. (2014), “Recovery capital, addiction theory, and the development of recovery communities”, Addicta, Vol. 2 No. 1, pp. 96-112

Further reading

Yates, R. (2012), “In it for the long haul: recovery capital, addiction theory and the inter-generational transmission of addictive behavior”, in Adan, A. and Vilanou, C. (Eds), Substance Abuse Treatment: Generalities and Specificities, Marge-Medica Books, Barcelona, pp. 35-51