The purpose of this paper is to present a case study of a programme aimed at raising standards of care and levels of professionalism in private, drug-free therapeutic communities (TCs) in Santa Catarina, Brazil.
The paper describes the Reviver intervention in detail and draws on subjective insights collected during its implementation.
Over 100 TCs applied to the Reviver project, of which 83 qualified to participate. The large majority of TCs were found to combine community-as-method, religious worship and abstinence in their treatment model.
The paper highlights the significant role religious organisations have in the treating substance dependency in Brazil and raises ethical and practical questions regarding the incorporation of religious TCs into mainstream public mental health provision.
The paper outlines the qualification process, control systems and monitoring procedures employed by the Reviver project.
The paper attends to the gap in English language publications regarding TCs in Brazil and raises important questions regarding the role of religion, faith and spirituality in the treatment of substance dependency.
McBride, R., Lemos, T., de Souza, M. and Goulão, J. (2018), "Therapeutic communities in Santa Catarina, Brazil", Therapeutic Communities: The International Journal of Therapeutic Communities, Vol. 39 No. 4, pp. 162-170. https://doi.org/10.1108/TC-05-2018-0015Download as .RIS
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Copyright © 2018, Emerald Publishing Limited
In Brazil, substance dependency is implicated in numerous public health challenges, including mental health, sexually transmitted infections, road traffic accidents and homicide (Bastos et al., 2002; Fischer et al., 2013; Gallassi et al., 2016). Of particular concern is crack cocaine dependency, with some suggesting that over one million Brazilians regularly consume crack (Dualibi et al., 2008; Galduróz et al., 2005). Consumption of crack is particularly high in urban areas among destitute, marginalised and excluded populations (Cruz et al., 2013). Deprivation and precarious living conditions combined with crack’s accessibility, addictive nature and stigmatisation means providing treatment services to crack consumers is complex and challenging (Fischer et al., 2013; Schlemper, 2018; Mesquita et al., 2000). Widespread crack consumption has thus placed an inordinate strain on public mental health service provision, which has failed to keep pace with the needs of hypervulnerable people who experience extreme inequality and severe social injustice.
In recent years, federal governments across Brazil have sought innovative policy solutions to bridge the current gap in alcohol and drug service provision. One such innovation has been the implementation of programmes aimed at regulating the large number of private, drug-free therapeutic communities (TCs) that exist throughout the country. In this paper we present a case study of the Reviver (“Revive”) programme, an initiative undertaken in the Brazilian Federal State of Santa Catarina to improve residential care for people substance dependency. The purpose of the paper is threefold: first, to review the literature regarding Brazilian TCs in order to identify their key characteristics and the treatment model they employ. Second, to describe the Reviver project in detail and sketch a profile of the private, drug-free TCs operating in Santa Catarina. Third, to highlight the ethical and practical challenges of regulating religious TCs (RTCs) and the need for greater research into the role of religion, faith and spirituality in the treatment of substance dependency.
Review of literature: therapeutic communities in Brazil
A large part of the twentieth-century drug consumption in Brazil was heavily policed through prohibition and criminalisation and public mental health was not a political priority (Oliveira, 2012). Consequently, alcohol and drug services were not developed by the state. In the 1970s, as Brazil underwent rapid urbanisation, alcohol and drug consumption increasingly became a public health problem, particularly within under-resourced, peri-urban communities. Religious and non-religious organisations began to fill this “care gap” by establishing residential services for people with substance dependency (Alves, 2009). Some of these private, drug-free TCs drew on the Minnesota Model and promoted trust in a divine power, mutual help and 12-step programme; others employed the Synanon Model and encouraged self-confidence, humility and work rather than belief in a higher self (Damas, 2013). In the 1990s, the number of TCs, particularly religious (RTCs), grew rapidly relational to burgeoning levels of crack consumption.
As we write, it is estimated that there are anywhere between 1,900 and 3,000 TCs in Brazil, which have between 60,000 and 80,000 residents per annum (IPEA, 2017; Perrone, 2014; Santos, 2014). Treatment is typically free and so highly accessible. This is reflected in the lived experiences of residents, which tend to have been shaped by poverty, low educational attainment, unemployment, interpersonal strife and involvement with criminal justice (Damas, 2013).
The literature suggests that there are two key characteristics of private, drug-free TCs in Brazil. First, TCs in Brazil are similar in structure, organisation and regime rational to the TC model developed in the USA for substance dependency (see De Leon, 1994; Melnick et al., 1997); an approach shown to reduce drug consumption while increasing employment (De Leon et al., 2000; Drake et al., 2008). As such, residents in Brazilian TCs are expected to be drug-free and perform different tasks, including self-care, food preparation, subsistence activities and educational and vocational training (IPEA, 2017). Residents are assigned roles, rights and responsibilities (Sabino and Cazenave, 2005). Group meetings, seminars, house meetings and general meetings that involve both residents and staff are significant elements of the treatment process employed by most TCs, while medication use, individual and group psychotherapies are also facilitated to provide psychological and social support (IPEA, 2017; Santos, 2014, 2016; Souza and Schlemper, 2015). TCs in Brazil thus employ an abstinence-only approach and “community-as-method” in an attempt to assist residents undergo a global change in lifestyle.
The second key characteristic of TCs in Brazil is the centrality of spirituality to the treatment process. One survey found that more than 90 per cent of TCs describe spirituality as a method of treatment (IPEA, 2017). Spirituality-as-treatment manifests in daily faith-based activities, including daily prayers and thanksgiving that structure the rhythm of the institutional regimen. Such faith-based activities aim to foster discipline and personal responsibility (Schempler, 2017) and guide a person towards “right living”. Substance dependency, and recovery from it, in Brazilian TCs is thus commonly framed as a spiritual problem, which can only be overcome through faith and the worship of God (Gomes, 2010; Sanchez and Nappo, 2008). The treatment process in Brazilian TCs thus adapts the TC model by inflecting practices of individual support, positive peer pressure, group integration, education and labour with penance and the seeking of absolution.
Until recently, private, drug-free TCs were not recognised as health or welfare facilities and remained independent of government regulation (Schlemper, 2017). In 2012, however, the national government initiated a policy to fund residential accommodation in TCs because of the inability of public health services to effectively respond to high levels of crack consumption (Carvalho et al., 2015; Cetolin et al., 2013; IPEA, 2017). Through the provision of public resources, federal states have sought regulatory control over private TCs in order to standardise care practices, increase technical expertise and improve the ethical basis of treatment (Alves, 2009; Schlemper, 2017, 2018). This has involved benchmarking and monitoring the performances of TCs that receive public funds (Santos, 2014). Consequently, policy makers have sought to develop regulatory controls that improve care practices and the management of drug-free residential TCs.
The financing of TCs, particularly RTCs, has, however, caused contention. Segments of the health community have voiced concerns that admission to RTCs is often predicated on religious conversion and abstinence. Religious conversion raises complex bioethical issues around agency, choice and equality (Schlemper, 2018), while abstinence-only methods contradict the National Policy on Drugs, which advocates harm reduction (Alves, 2009). Furthermore, while faith-based approaches have been found to have a range of benefits within qualitative samples (Sanchez and Nappo, 2008), there is a lack of research evidence examining the effectiveness of RTCs on a large scale (Damas, 2013). It is unknown whether or not the incorporation of faith-based activities impacts the efficacy of the community-as-method approach. In addition, concerns have been raised about the educational qualifications of those who work in and manage RTCs (IPEA, 2017). Further criticism comes from those who object to the outsourcing of public services to the private sector (Santos, 2014), while others have critiqued the logic of exclusion RTCs employ, which contravenes the community care approach promoted in public mental health services (Bolonheis-Ramos and Boarini, 2015). Nevertheless, a counter argument to these complaints is that since there are thousands of RTCs across Brazil, providing care to tens of thousands of people per annum, it is impossible for the government to ignore or disregard them (Damas, 2013). Rather, it could be argued that the government has an ethical responsibility to ensure that private, religious institutions uphold best practice and work to protect the rights of the vulnerable people who access them.
Description of setting
Santa Catarina is one of Brazil’s 27 federal states and is located in the “south” region. It has approximately seven million inhabitants of who 86 per cent identify as “white”, while 85 per cent live in urban areas. The average monthly income is R$1,458.00 (£296). The human development index is 0.774, the third best in the country, while the state has the best social and educational indicators in relation to poverty rate, income levels, literacy and school attendance within Brazil. Nevertheless, consumption of tobacco, alcohol and illicit substances remains public health challenges.
Santa Catarina has a high prevalence of HIV/AIDS (14.2 per cent), hepatitis B (7.7 per cent) and hepatitis C (10.4 per cent), which have been linked to the consumption of drugs (Brazilian Secretariat for Drug Policy, 2009). Additionally, hospital admissions for alcohol or illicit drugs (117 hospitalisations per 100,000) in Santa Catarina are high when compared to the national average (77 hospitalisations per 100,000) (Durate et al., 2009). Another study found that 11.4 per cent of people in Santa Catarina “abuse” alcohol, and men consume three times more alcohol than women (IBGE, 2014). The southern region of Brazil (which includes Santa Catarina) has been found to consume less cocaine than other regions (Laranjeira, 2014). However, ecstasy consumption is double compared to other regions. This mirrors trends observed in Europe and the USA where cocaine consumption has been replaced by ecstasy (Laranjeira, 2014). Around 5.4 per cent of adolescents aged 13–17 years living in Santa Catarina report smoking tobacco in the last month (national average of 5.6 per cent), 33.8 per cent report drinking alcohol (national average 23.8 per cent) and 5.3 per cent report using illicit drugs (national average 4.2 per cent) (IBGE, 2016). It has been estimated that there are approximately 100 TCs in operation in Santa Catarina that provide drug-free residential services (Roeder, 2012).
Description of intervention
Reviver was launched in August 2013 and finished in November 2016. Led by Santa Catarina’s Department of Health, Reviver was developed in collaboration with the Brazilian Therapeutic Community Federation/Santa Catarina, Santa Catarina’s Therapeutic Community Association, the Foundation for Research and Innovation Support of Santa Catarina, and a team of academics. The overall aim of Reviver was to improve the care received by people with needs arising from the use of alcohol, crack and other substances in residential services. To achieve this, Reviver implemented activities in three programmatic areas: research into treatment models and systems of practice; development of information systems and a drug policy observatory; and enhancement of the care provided in drug-free TCs.
Following the launch of Reviver, two public announcements inviting residential care services to apply for financial and technical resources were made. The application process required TCs to submit documentation, including up-to-date fiscal and tax documentation as well as evidence of sanitary and security requirements. Such documentation was used to determine to what extent, or not, TCs met national standards of care, as set out in Brazil’s National Policy on Drugs (CONAD) and the requirements of the Statute of the Child and Adolescent (ECA) and the Federal Constitution. In particular, TCs were evaluated against National Agency of Sanitary Surveillance (ANVISA) standards, which sets out the health and safety requirements for institutions providing residential care services with substance dependency in Brazil (for full details see Souza and Scarduelli, 2015).
If TCs qualified to participate they were subject to a site visit and evaluated against ANIVISA standards in terms of physical infrastructure, therapeutic programme, social reintegration, staffing and management. This enabled the Reviver team to benchmark each TC’s performance, identify required improvements and monitor progress. In this regard, ten knowledge exchange conferences were held with approximately 150 participants in each (two personnel from each TC were obliged to take part in each conference). The aim of the knowledge exchange conferences was to assist TCs align existing practices with the systematised theoretical foundations applicable to the planning and functioning of a drug-free TC following De Leon’s (2003) method. This included instruction in the “whole person” approach, which frames dependency as having multiple determinants within a person’s lived experience; the “community-as-method” treatment model, which considers all interactions, relationships and activities to have the potential to contribute to therapeutic and educational change; and, the importance of the “stages of change”, which recognises the important impact induction, primary treatment and re-entry phases have on a person’s motivation and readiness as well as affiliations and identity (see Souza and Schlemper, 2015; Souza, Serrano, Velloso, Schlemper, Oliveira, Melo and Lemos, 2017).
Reviver was managed by a multidisciplinary team consisting of experts from mental health, administration, accounting, law, education and information technology. Central to the management of Reviver was the implementation of a range of administrative controls. This included a requirement for all participating TCs to submit documentation pertaining to their financial management and an annual financial report. Furthermore, a system of resident verification was developed, which employed facial recognition technology, to monitor the number of residents and length of stay of residents in each TC. Such systems helped to prevent fraudulent claims and also made it possible to verify TCs adoption of agreed standards and to identify emerging issues.
Case study: therapeutic communities in Santa Catarina
A total of 110 applications were received, of which 83 TCs qualified to participate in Reviver. There was considerable variety among qualifying TCs. Residential capacity ranged between 30 and 60 beds; some were adult only, while others also allowed adolescents to stay. The majority of TCs were not “secure”, with residents, in theory, able to leave if they wanted. However, most were located in rural areas that were remote and difficult to access. This made it difficult for residents to leave on a whim. The remoteness could also lead residents to become isolated from family and friends. Some allowed residents to watch TVs, use mobile phones and the internet, while others did not. Some offered a wide array of amenities and had a high standard of facilities, while others were rudimentary and lacked basic sanitation. For the most part, the physical infrastructure of TCs complied with national standards.
Over the course of the Reviver project, the 83 participating TCs received a total of 3,032 people of which approximately 1,000 were funded. The large majority of residents were adult males aged 16–60 years old who came from impoverished backgrounds. Residents could enter TCs on the basis of self-referral, professional referral and court referrals (which gave people the choice of a stay in a TC or be sent to prison). They were typically expected to stay between nine and 12 months. However, a considerable number drop out before completing this timeframe.
The majority of TCs were found to have inadequate staffing. Many were staffed predominately by mentors who had “graduated” from the TC and continued to live there (with periodic input from professional staff). While graduates could be considered “experts-by-experience”, they typically lacked technical knowledge and served predominately as monitors. A minority of TCs were provided with input from psychologists, nurses and/or social workers.
Among TCs the 12-step programme was found to be the primary treatment philosophy. The 12-step model used was typically premised on the assumption that people cannot overcome addictions unless they surrender to a higher power (i.e. the Minnesota Model). The large majority of TCs embraced the biopsychosocial model of addiction and did not deny or prevent pharmacological and psychological treatment. Typically, residents were allowed to use medication as long as it was prescribed by a physician. In line with the 12-step model, TCs generally adopted an abstinence approach and required residents to “get clean” during the first two weeks of their stay. Residents were then expected to become active members of the community and take responsibility for chores, such as preparing meals, gardening or animal husbandry. Overall, however, the majority of qualifying TCs did not have an adequate therapeutic programme in place. This was connected to the prevailing influence of religious doctrine and emphasis on faith-based activities.
The majority of TCs (86.5 per cent) that qualified promoted a particular religious denomination: 60 per cent Evangelic, 16 per cent Catholic, 5 per cent Lutheran, 3.5 per cent Baptist and 2 per cent Adventist. The remaining TCs were non-religious with a secular orientation (13.5 per cent) and one was linked to Freemasonry. In RTCs, residents were expected to take part in faith-based activities embedded in the daily routine of the institution: prayers in the morning and at night, mealtime thanksgiving, hymns of praise, the incorporation of biblical themes into artistic activities and daily or weekly worship services. Some RTCs were dogmatic and expected residents to be celibate, embrace poverty and dedicate their life to others. Faith-based activities were found to be undertaken with greater frequency within Evangelical TCs.
Reintegration was found to be a challenge for all TCs, with institutionalisation found to be a risk within some RTCs. Additionally on leaving an RTC, former residents were expected to become a practising member of the denomination and volunteer with a particular church. Some former residents benefited from having a faith-based social network in the community, which could aide in their recovery. For others it was experienced as exploitative.
Burgeoning levels of crack consumption and inadequate public alcohol and drug services have led private, drug-free residential TCs to become prominent features of Brazilian mental health care landscape. This has resulted in large numbers of hypervulnerable people from precarious communities accessing long-term, residential services predicated on religious conversion and abstinence-only treatment models. The Brazilian Government has responded to this situation by seeking innovative approaches to improving the care practices and the management systems of these private TCs, which have historically been allowed to develop free of regulation.
In Santa Catarina, the Reviver project aimed to accredit drug-free residential services through a system of assessment, capacity building, knowledge generation and ongoing evaluation. The aim was to provide TCs with funding so that they would adopt national standards of care and provide technically and ethically sound appropriate services. The project’s activities sought to: identify existing TCs with sound operating structures and appropriate technical staff; provide qualifying TCs with financial resources and technical staff and managers with training; and recognise qualifying TCs as health units and part of the formal health system. One major challenge encountered in the Reviver project was proselytising.
The large majority of TCs in Santa Catarina were found to view substance dependency and recovery through a religious lens. As such, the basic community-as-method treatment model was modified with “theotherapy”, with Christian conceptions of social life promoted as central to addiction and recovery from it (Valderrutén, 2008). Consequently, on initial inspection, many qualifying RTCs predicated treatment access and success on religious conversion to a given doctrine (Souza and Gomes, 2017). This reflected a solemn belief among staff in RTCs, and among many residents, that faith and worship in God has restorative and healing power. This belief is reflected in treatment approaches employed, which focus on encouraging residents to “live right” by adopting religious values and a faith-based daily routine. In this way, RTCs seek to discipline residents in line with doctrinal norms, values and attitudes. As a result, RTCs only consider former residents who become active members of the church, either by remaining in the TC as a mentor or by actively participating in church life in the community, to have recovered from addiction.
The provision of drug and alcohol services to excluded and marginalised people as a means to proselytise is contrary to bioethical standards of practice and impedes Constitutional rights, including equality between different religious groups and the freedom to embrace no religion. A central challenge encountered during the Reviver project was therefore how to reduce the focus on religious conversion among participating RTCs while simultaneously promoting the principles of biopsychosocial treatment, advocating the role of qualified health professionals, and the importance of flexible therapeutic programs. The Reviver programme sought to overcome this challenge by providing comprehensive training to technical staff and managers in the biopsychosocial treatment of substance dependency, providing funding that enabled TCs to hire psychologists and social workers, and creating referral links between TCs and the public health service. In so doing, the Reviver project generated a community of practice among academics, government, professionals and religious organisations focused on improving the support and care in private, drug-free residential services.
The Reviver case study illustrates the extent to which faith and spirituality permeate private, drug-free TCs in Brazil. As historians have shown, the TC treatment model has its roots in religious and political movements of the eighteenth and nineteenth century (Campling, 2001; Whiteley, 2004). In England, the Tuke family established the Retreat (1796) and developed a treatment process infused with Quaker faith (Kennard, 2004; McBride, 2017). Likewise, Yates et al. (2006, p. 7) showed how in Germany TCs were started by the work of a Romanian Orthodox Priest and how in Italy priest Don Mario Picchi established San Carlos and went on to found a hugely influential training programme, which in turn influenced the development of drug-free TCs in Spain. Glaser (1981), meanwhile, contended that virtually all drug-free TCs in North America may be traced through Synanon, Alcoholics Anonymous and the Oxford Group: an explicitly religious organisation aimed at the spiritual rebirth of all humanity. Yet despite this golden thread, which ties the TC treatment model to religious organisations of different denominations around the world, there remains little discussion regarding religion, faith and spirituality in contemporary substance dependency treatment.
Experiences in the Reviver project suggest that faith and spirituality are dynamic personal characteristics that impact a person’s motivation and readiness to engage in treatment. Daily practices of religious worship are designed to promote the internationalisation of faith-based messages in order to promote compliance, conformity and integration into a faith-based community. The degree to which a person internalises these messages will shape whether or not they assume a faith-based identity, affiliate with the religious community and/or consciously become involved in religious activities on release. As such, increased faith and/or greater spiritual appeasement may serve as a motivational factor to remain in treatment and as supportive factor on re-entry. However, the emphasis on religious conversion and the compulsory nature of faith-based activities can also be experienced as an oppressive form of social control. Furthermore, the heavy expectations placed on graduates to “volunteer” either as a mentor or in the community expose former residents to potentially exploitative situations. These insights suggest a need for research to be undertaken, across cultural contexts, that investigates faith and spirituality in TCs, and the extent to which these dynamic characteristics embolden, or erode, individual readiness and recovery.
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The Reviver project was funded by the Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina (FAPESC). Funding was also received from Santander UK, who provided a mobility grant to the first author.
About the authors
Ruari-Santiago McBride is PhD Student at the School of Sociology and Centre for Excellence Public Health, Queen’s University Belfast, Belfast, UK.
Tadeu Lemos is Doctor, Specialist in Chemical Dependency, Psychopharmacologist, Master and Doctor of Science/Neurosciences and Associate Professor at the Universidade Federal de Santa Catarina (UFSC), Florianópolis, Brazil.
Maria de Lourdes de Souza is based at the Universidade Federal de Santa Catarina (UFSC), Florianópolis, Brazil.
João Castel-Branco Goulão is based at the Ministério da Saúde de Portugal, Lisbon, Portugal.