What is the
typical length of treatment
in a therapeutic community?

In general, individuals progress through drug addiction treatment at varying speeds, so there is no predetermined length of treatment. Those who complete treatment achieve the best outcomes, but even those who drop out may receive some benefit.

Good outcomes from TC treatment are strongly related to treatment duration, which likely reflects benefits derived from the underlying treatment process. Still, treatment duration is a convenient, robust predictor of good outcomes. Individuals who complete at least 90 days of treatment in a TC have significantly better outcomes on average than those who stay for shorter periods.

Traditionally, stays in TCs have varied from 18 to 24 months. Recently, however, funding restrictions have forced many TCs to significantly reduce stays to 12 months or less and/or develop alternatives to the traditional residential model (see "How else can TCs be modified?").

For individuals with many serious problems (e.g., multiple drug addictions, criminal involvement, mental health disorders, and low employment), research again suggests that outcomes were better for those who received TC treatment for 90 days or more. In a DATOS study, treatment outcomes were compared for cocaine addicts with six or seven categories of problems and who remained in treatment at least 90 days. In the year following treatment, only 15 percent of those with over 90 days in TC treatment had returned to weekly cocaine use, compared to 29 percent of those who received over 90 days of outpatient drug-free treatment and 38 percent of those receiving over 3 weeks of inpatient treatment.

The relationship between retention and good treatment outcomes identified in DATOS has been replicated in many studies. However, many TCs have a high dropout rate, although about one-third of dropouts seek readmission. A significant research effort is underway to better understand and improve TC treatment retention by examining external factors, program services and processes, and attributes of individuals in treatment.

External factors related to retention include level of association with family or friends who use drugs or are involved in crime, and legal pressures to enroll in treatment. Inducements -- sanctions or enticements by the family, employment requirements, or criminal justice system pressure -- can improve treatment entry and retention and may increase the individual's internal motivation to change with the help of treatment.

In the TC, the level of treatment engagement and participation is related to retention and outcomes. Treatment factors associated with increased retention include having a good relationship with one's counselor, being satisfied with the treatment, and attending education classes. One study tested a strategy to enhance motivation by increasing new residents' exposure to experienced staff, in contrast to the more traditional approach of largely relying on junior staff as role models. The senior staff provided seminars for new residents based on their own experiences with retention-related topics. This strategy appeared to increase the 30-day retention rate and was particularly effective for those whose pretreatment motivation was the weakest.

Important attributes linked to treatment retention include self-esteem, attitudes and beliefs about oneself and one's future, and readiness and motivation for treatment. Retention can be improved through interventions to address these areas. One approach focuses on teaching cognitive strategies to improve self-esteem, develop "road maps" for positive personal change, improve understanding of how to benefit from drug abuse treatment, and develop appropriate expectations for treatment and recovery. This approach was particularly effective for individuals with lower educational levels.

What are the fundamental components
of therapeutic communities?

Research spanning more than 30 years has identified key concepts, beliefs, clinical and educational practices, and program components common to most TC programs. These elements reflect the two principles that drive TC operations: the community as change agent and the efficacy of self-help.

Typically, TCs are residential facilities separate from other programs and located away from the drug-related environment. As a participant in the community, the resident in treatment is expected to adhere to strict and explicit behavioral norms. These norms are reinforced with specific contingencies (rewards and punishments) directed toward developing self-control and responsibility. The resident will progress through a hierarchy of increasingly important roles, with greater privileges and responsibilities. Other aspects of the TC's "community as method" therapeutic approach focus on changing negative patterns of thinking and behavior through individual and group therapy, group sessions with peers, community-based learning, confrontation, games, and role-playing.

TC members are expected to become role models who actively reflect the values and teachings of the community. Ordered routine activities are intended to counter the characteristically disordered lives of these residents and teach them how to plan, set, and achieve goals and be accountable.

Ultimately, participation in a TC is designed to help people appropriately and constructively identify, express, and manage their feelings. The concepts of "right living" (learning personal and social responsibility and ethics) and "acting as if" (behaving as the person should be rather than has been) are integrated into the TC groups, meetings, and seminars. These activities are intended to heighten awareness of specific attitudes or behaviors and their impact on oneself and the social environment.

How are therapeutic
communities structured?

TCs are physically and programatically designed to emphasize the experience of community within the residence. Newcomers are immersed in the community and must fully participate in it. It is expected that in doing so, their identification with and ties to their previous drug-using life will lessen and they will learn and assimilate new prosocial attitudes, behaviors, and responsibilities.

Although the residential capacity of TCs can vary widely, a typical program in a community-based setting accommodates 40 to 80 people. TCs are located in various settings, often determined by need, funding sources, and community tolerance. Some, for example, are situated on the grounds of former camps and ranches or in suburban houses. Others have been established in jails, prisons, and shelters. Larger agencies may support several facilities in different settings to meet various clinical and administrative needs.

In DATOS, there was an average of one counselor reported for every 11 residents in treatment. About two-thirds of the counseling staff had themselves successfully completed drug abuse treatment programs. Increasingly, TCs rely on degreed staff (e.g., social workers, nurses, and psychologists) for some aspects of treatment.

How is treatment provided
in a therapeutic community?

TC treatment can be divided into three major stages.

Stage 1. Induction and early treatment typically occurs during the first 30 days to assimilate the individual into the TC. The new resident learns TC policies and procedures; establishes trust with staff and other residents; initiates an assisted personal assessment of self, circumstances, and needs; begins to understand the nature of addiction; and should begin to commit to the recovery process.

Stage 2. Primary treatment often uses a structured model of progression through increasing levels of prosocial attitudes, behaviors, and responsibilities. The TC may use interventions to change the individual's attitudes, perceptions, and behaviors related to drug use and to address the social, educational, vocational, familial, and psychological needs of the individual.

Stage 3. Re-entry is intended to facilitate the individual's separation from the TC and successful transition to the larger society. A TC graduate leaves the program drug-free and employed or in school. Postresidential aftercare services may include individual and family counseling and vocational and educational guidance. Self-help groups such as Alcoholics Anonymous and Narcotics Anonymous are often incorporated into TC treatment, and TC residents are encouraged to participate in such groups after treatment.

What is daily life like in a therapeutic community? The TC day is varied but regimented. A typical TC day begins at 7 a.m. and ends at 11 p.m. and includes morning and evening house meetings, job assignments, groups, seminars, scheduled personal time, recreation, and individual counseling. As employment is considered an important element of successful participation in society, work is a distinctive component of the TC model. In the TC, all activities and interpersonal and social interactions are considered important opportunities to facilitate individual change. These methods can be organized by their primary purpose, as follows: Clinical groups (e.g., encounter groups and retreats) use a variety of therapeutic approaches to address significant life problems. Community meetings (e.g., morning, daily house, and general meetings and seminars) review the goals, procedures, and functioning of the TC. Vocational and educational activities occur in group sessions and provide work, communication, and interpersonal skills training. Community and clinical management activities (e.g., privileges, disciplinary sanctions, security, and surveillance) maintain the physical and psychological safety of the environment and ensure that resident life is orderly and productive.