The primary goal of the TC is to foster personal growth (Butt, 1990) through a process of global change that includes abstinence from drug use, elimination of antisocial behaviour, the expression of prosocial attitudes and behaviours, the acquisition of social and living skills, and the development of employability, (Butt, 1990; Nielsen & Scarpitti, 1997; Mattick & Hall, 1993; De Leon, 1994).
Staff members working in a TC consist of either lay counselors (ex-addicts) (White, 1991), a range of professionals that include social workers, psychologists, and psychiatrists (Cancrini, De Gregorio & Cardella, 1994) or a combination of both (Butt, 1990). The relatively few staff members monitor and evaluate resident’s status, supervise groups, assign and supervise job functions, and oversee house operations (De Leon, 1994). Residents are responsible for their daily living requirements, maintaining their living quarters, and assisting in the general upkeep of the TC (Nielsen ; Scarpitti, 1997).
Contemporary TCs usually adopt a non-medical approach (Hall, Chen ; Evans, 1995), offer programs ranging from 3mths to 18mths duration (Ghodse, 1995), operate on a 24 hour live-in basis, and conduct random urine testing (Charuvastra, Rehmar, Paredes ; MCBride, 1989). TCs provide the individual with a structured drug-free environment and clear boundaries (Nielsen ; Scarpitti, 1997; Butt, 1990) so as to encourage individual responsibility for the self and group responsibility for the community (Blake, Millard ; Roberts, 1984). In addition, there is a defined system of rewards for good behaviour (e. g., privileges) and punishments (e. g. , sanctions and penalties) for not adhering to community guidelines (Ghodse, 1995; De Leon, 1994; Butt, 1990).
Although the TC fosters a trial and error learning process in which the individual can fail safely (De Leon, 1991b), any infringement of the cardinal rules (no violence, no stealing, no sex, no drugs) often results in immediate discharge (Butt, 1990; Glaser, 1981). Rehabilitation and recovery unfolds as a developmental process that occurs in a social learning setting, and often involves stages of sequenced incremental learning as the individual progresses through various phases (e.g. , orientation, primary treatment, graduation, re-entry, and aftercare) in the program (De Leon, 1994).
Although individual counseling is usually available to assist residents in resolving underlying or core issues that led to their drug abuse, there is usually an emphasis on group methods (Nielsen ; Scarpitti, 1997). De Leon (1994) suggests that the most important mechanism for change is the community of peers who confront their fellow resident/s (in encounter groups) when old values and behaviours are displayed, provide positive and negative reinforcements to elicit appropriate behaviour, and serve as role models.
The principal goal for the individual is re-entry into society (Hall, Chen ; Evans, 1995) however “relapse is the rule across all treatment approaches” (De Leon, 1994, p. 1225) and usually occurs within the first 90 days (Butt, 1992). In an effort to reduce relapse individuals are, depending on their level of progress, allowed day, overnight, and weekend leave so as to experience and overcome high-risk situations, and reintegrate back into mainstream society (Butt, 1992).
In addition, the majority of TCs provide additional support through aftercare programs that include re-entry or halfway houses (De Leon, 1991b), and emphasise the use of self-help groups such as AA, and NA (Troyer, et al. ; 1995; Butt, 1990). Wexler’s (1995) suggestion that AA is primarily a support model whereas the TC is a self-help intervention model warrants some thought given that both treatment interventions adopt similar practices. TCs and AA both advocate abstinence, are peer based programs that employ confrontational techniques within a group format, and view the individual as being responsible for their own recovery.
In addition, TCs and AA adopt similar theoretical approaches, provide a drug-free environment for social interaction, and emphasise learning new skills. While it would also appear that the majority of individuals who access AA and TCs are experiencing severe drug (Condelli & Hubbard, 1994; Weiss et al. , 2000), and alcohol problems (Tonigan, Toscova & Miller, 1996), TCs appear to acknowledge the uniqueness of each individual. In AA, all members follow the same regime whereas individual differences are recognized in TCs through specific treatment plans that change the emphasis, not the course, of their experience in the TC (De Leon, 1994).
TCs also distinguish individuals along dimensions of psychological dysfunction and social deficits rather than according to drug-use (e. g. , alcoholics versus social drinkers) patterns (De Leon, 1994; Jarvis, Tebbutt & Mattick, 1995). In contrast to AA, TCs usually have exclusion criteria (e. g. , psychopathological disorders) so as to ensure a safe and predictable environment for residents, especially in relation to female residents. However, unlike AA, the majority of TCs in Australia are not a viable alternative for some women who have children.
Although the research from studies indicates positive outcomes with AA (Tonigan, Toscova & Miller, 1996; Timko et al. , 2000; Mann, et al. , 1991), and TCs (Page & Mitchell, 1988; Simpson & Sells, 1990, cited in Platt, Husband & Taube, 1991), both treatment interventions are difficult to evaluate due to significant methodological constraints, and the influence of extraneous variables. AA has been criticised for its lack of client monitoring and treatment evaluation, and the use of non-professionals helping people who may have severe psychological disorders (Major, 2000).
In contrast, TCs have been accused of providing a pseudo-environment where residents risk becoming dependent on the TC itself, and delay the chance to implement what they have learned (Butt, 1990). In addition to the limitations associated with self-report data, TCs experience high attrition rates (De Leon & Schwartz, 1984) and encounter difficulties in locating ex-residents during follow-up studies (Charuvastra, et al. , 1989), whereas controlled trials on the effectiveness of AA are difficult as AA insists on anonymity, and membership is voluntary so no one can be turned away (White, 1994).
It is evident from the literature discussed throughout this paper that the boundaries between AA, and TCs programs are somewhat blurred. While there were notable similarities and differences between AA and TCs, the AA program could be considered somewhat disempowering as members view themselves as being in a constant state of recovery that requires life-long vigilance (Troyer et al. , 1995). Fortunately, AA is widespread, easily accessed, and cost nothing to attend (Saunders, 1998).
Although the evidence to support the effectiveness of either approach appears somewhat tentative, the diffusion (e. g., settings, countries) of AA (Makela, 1991), and TCs (Cancrini, Gregorio & Cardella, 1994) suggests that these two interventions are considered to be, at least for some individuals, viable options for the treatment of alcohol and drug abuse.
References Alcoholics Anonymous (1976). Alcoholics Anonymous. New York: Alcoholics Anonymous World Services, Inc. Blake, R,. Millard, D. , & Roberts, J. (1984). Therapeutic community principles in an integrated local authority mental health service. The International Journal of Therapeutic Communities, 5 (4), 243-274. Butt, L. (1990). Therapeutic communities.
Connexions, 10 (1), 19-23. Butt, L. (1992). We help ourselves. Connexions, 12 (4), 14-16. Charuvastra, V. , Rehmar, R. , Paredes, A. , & MCBride, M. (1989). Drug-free therapeutic: A ten-year follow up. Addictive Behaviors, 14, 343-345. Clarke, C. , & Saunders, J. (19 ). Alcoholism and problem drinking: theories and treatment. In… Craig, R. (1995). The role of personality in understanding substance abuse. Alcoholism Treatment Quarterly,13 (1), 17-27. Cancrini, G. , Gregorio, F. , & Cardella, F. (1994). Therapeutic communities. The Journal of Drug Issues, 24 (4), 639-656. Condelli, W. , & Hubbard, R. (1994).
Relationship between time spent in treatment and client outcomes from therapeutic communities. Journal of Substance Abuse Treatment, 11, 25-33. De Leon, G. (1994). Therapeutic communities. In M. Glanter, & H. Kleber (Eds. ), American psychiatric press textbook of substance abuse (pp. 391-414). Washington DC: American Psychiatric Press. De Leon, G. (1991). The therapeutic community and behavioural science. The International Journal of Addictions, 25 (12A), 1537-1557. De Leon, G. (1991b). Aftercare in therapeutic communities. The International Journal of Addictions, 25 (9A & 10 A), 1225-1237. De Leon, G. , & Schwartz, S. (1984).
Therapeutic communities: What are the retention rates? American Journal of Drug and Alcohol Abuse, 10 (2), 267-284. Dodd, M. (1997). Social model of recovery: Origin, early features, changes, and future. Journal of Psychoactive Drugs, 29 (2), 133-139. Drummond, D. (1991). In I. Glass (Ed. ), The international handbook of addiction behaviour, pp. 5-10. New York: Tavistock/Routledge. Fiorentine, R. (1999). After drug treatment: Are 12-Step programs effective in maintaining abstinence? American Journal of Drug and Alcohol Abuse, 25 (1), 93-116. Gaudry, E. (1994). Recovery from alcoholism: A guide for alcoholics and those who help them.
In A handbook of alcoholism treatment approaches, pp. 183-193. Victoria, Australia: Collins Dove. Ghodse, H. (1995). Drugs and addictive behaviour: A guide to treatment (2nd ed. ). London: Blackwell Science Ltd. Glaser, F. (1981). The origins of the drug-free therapeutic community. British Journal of Addiction, 76, 13-25. Goold, R. (2001). Alcoholics Anonymous: Its role in the drug field. Connexions, 21 (1), 2-4. Hall, W. , Chen, R. , & Evans, B. (1995). Changes in the characteristics of clients admitted to an Australian therapeutic community, “The Buttery”, 1980-92. Drug and Alcohol Review, 14, 125-129.
Inaba, D. , & Cohen, W. (2000). Uppers, downers, all arounders: Physical and mental effects of psychoactive drugs (4th ed. ). Ashland, OR: CNS Publications. Jarvis, T. , Tebbutt, J. , & Mattick, R. (Eds. ). (1995). Treatment approaches for alcohol and drug dependence: An introductory guide. New York: John Wiley & Sons. Jurd, S. (1996). Addiction as a disease. In C. Wilkinson, & B. Saunders, (Eds. ), Perspectives on addiction (pp. 2-8). Perth, Australia: William Montgomery Pty Ltd. Makela, K. (1991). Social and cultural preconditions of Alcoholics Anonymous (AA) and factors associated with the strength of AA.
British Journal of Addiction, 86, 1405-1413. Mann, R. , Smart, R. , Anglin, L. , & Adlaf, E. (1991). Reductions in cirrhosis deaths in the United States: Associations with per capita consumption and AA membership. Journal Studies of Alcohol, 52, 361-365. Major, C. (2000). Stories around the campfire: AA in Australia and beyond. Connexions, 20 (4), 2-7. Mattick, R. , & Hall, W. (Eds. ). (1993). A treatment outline for approaches to opioid dependence: quality assurance project (Monograph No. 21). Canberra: Australian Government Publishing Service. Miller, W. , & Kurtz, E. (1994).
Models of alcoholism used in treatment: Contrasting AA and other perspectives with which it is often confused. Journal Studies of Alcohol, 55, 159-166. McCrady, B. , Epstein, E. , & Hirsch, L. (1996). Issues in the implementation of a randomized clinical trial that includes Alcoholics Anonymous: Studying AA-related behaviours during treatment. Journal of Studies on Alcohol, 57, 604-612. McCullough, C. (1995). Nobody’s victim: Freedom from therapy and recovery. New York: Clarkson Potter/Publishers. McKay, J. , McLellan, A. , Alterman, A. , Cacciola, J. , Rutherford, M. , ; O’Brien, C. (1998).
Predictors of participation in aftercare and self-help groups following completion of intensive outpatient treatment for substance abuse. Journal Studies of Alcohol, 59, 152-162. Montgomery, H. , Miller, W. , & Tonigan, J. (1995). Does alcoholics anonymous involvement predict treatment outcome? Journal of Substance Abuse Treatment, 12, 241-246. Monras, M. , & Gual, A. (2000). Attrition in group therapy with alcoholics: a survival analysis. Drug and Alcohol Review, 19, 55-63. Nielsen, A. , & Scarpitti, F. (1997). Changing the behaviour of substance abusers: Factors influencing the effectiveness of therapeutic communities.
Journal of Drug Issues, 27 (2), 279-298. Page, R. , & Mitchell, S. (1988). The effects of two therapeutic communities in illicit drug users between 6 months and 1 year after treatment. The International Journal of the Addictions, 23 (6), 591-601. Pisani, V. , Fawcett, J. , Clark, McGuire, M. (1993). The relative contributions of medication adherance and AA meeting attendance to abstinent outcone for chronic alcoholics. Journal Studies of Alcohol, 54, 115-119. Platt, J. Husband, S. , & Taube, D. (1991). Major psychotherapeutic modalities for heroin addiction: A brief overview.
The International Journal of the Addictions, 25 (12A), 1453-1477. Rivers, (1994). Alcohol and human behaviour: Theory, research, and practice. Englewood Cliffs, NJ: Prentice Hall. Saunders, J. (1998). Making choices. Drug and Alcohol Review, 17, 149-152. Snow, M. , Prochaska, J. , & Rossi, J. (1994). Processes of change on Alcoholics Anonymous: Maintenance factors in long-term sobriety. Journal Studies of Alcohol, 55, 362-371. Timko, C. , Moos, R. , Finney, J. , & Lesar, M. (2000). Long-term outcomes of alcohol use disorders: Comparing untreated individuals with those in Alcoholics Anonymous and formal treatment.
Journal Studies of Alcohol, 61, 529-540. Tonigan, J. , Toscova, R. , & Miller, W. (1996). Meta-analysis of the literature on Alcoholics Anonymous: Sample and study characteristics moderate findings. Journal Studies of Alcohol, 57, 65-72. Troyer, T. , Acampora, A. , O’Connor, L. , ; Berry, J. (1995). The changing relationship between therapeutic communities and 12-Step programs: A survey. Journal of Psychoactive Drugs, 27, 177-180. Wallace, J. (1993). Modern disease models of alcoholism and other chemical dependencies: The new biopsychosocial models.
Drugs ; Society, 8 (1), 69-87. Watson, L. (1991). Paradigms of recovery: Theoretical implications for relapse prevention in alcoholics. Journal of Drug Issues, 21 (4), 839-858. Weiss, R. , Griffin, M. , Gallop, R. , Luborsky, L. , Siqueland, L. , Frank, A. , Onken, L. , Daley, D. , ; Gastfriend, D. (2000). Predictors in self-help group attendance in cocaine dependent patients. Journal Studies of Alcohol, 61, 714-719. Wexler, H. , Falkin, G, ; Lipton, D. (1990). Outcome evaluation of a prision therapeutic community for substance abuse treatment.
Criminal Justice and Behavior, 17 (1), 71-92. Wexler, H. (1995). The success of therapeutic communities for substance abusers in American prison. Journal of Psychoactive Drugs, 27, 57-66. Winters, K. , Stinchfield, R. , Opland, E. , Weller, C. , ; Latimer, W. (2000). The effectiveness of the Minnesota Model approach in the treatment of adolescent abusers. Addiction, 95 (4), 601-612. White, J. (1991). Drug dependence. Englewood Cliffs, NJ: Prentice Hall. Yalisove,D. (1998). The origins and evolution of the disease concept of treatment. Journal Studies of Alcohol, 59, 469-476.