Annual World Conference on Therapeutic Communities

September 29-30, 2000
San Francisco, CA

Meeting Summary

• Overview the state of the science in therapeutic community research
• Forge a partnership between the TC service provider community and researchers
• Discuss prominent TC research issues from both the program and provider perspectives
• Present new directions for the topical focus and conduct of future TC research

The meeting was co-sponsored by NIDA and the Therapeutic Communities of America (TCA). The chair of the meeting, Dr. Bennett Fletcher, Chief of NIDA's Services Research Branch, provided a conceptual framework for setting meeting priorities. Dr. Alan Leshner, Director of NIDA, challenge the researchers to take TC research to the "next level." Mr. Kevin McEneaney, President of TCA, challenged providers to open their doors to researchers. A series of presentations by both researchers and leaders in the TC provider community followed. Attendees concluded with an open discussion on ways to shift TC research focus on to ways of improving efficiency, quality, and effectiveness.

Dr. Alan Leshner, NIDA Director addressing the TC Conference in San Francisco.

Dr. Bennett Fletcher, Chief of NIDA's Services Research Branch in Bethesda Maryland, opened the conference. He welcomed the guests and charged the conference to set a new direction for TC research that will be set in partnership by both practitioners and the research community. In his remarks, Dr. Fletcher pointed out that for over 25 years, the National Institute on Drug Abuse (NIDA) has funded research examining drug abuse treatments (DATs) and their delivery in therapeutic community (TC) settings. The majority of treatment research has focused on determining the efficacy and effectiveness of DAT. In a sense, most research tried to determine if DAT worked. The results from that research overwhelmingly shows that DAT in TC settings is not only effective at helping participants reduce drug abuse, but TC treatment is also effective in reducing criminality, restoring people to productive roles in society, and helping to reduce ancillary medical problems that affect the public health such as HIV/AIDS, Hepatitis, and venereal diseases.

Having established that TCs are an effective method for delivering DAT services, TCs are being more widely applied than ever in their history. In recent years, TCs have been modified for a variety of special populations. Most significant of the new applications of TCs has been the burgeoning growth of TCs in the nation's prisons. Contrary to commonly held beliefs about the role of motivation in TC effectiveness, research has shown that TCs can be effective for probationers, prisoners, and parolees Ð people whose participation may have been, at least initially, coerced.

Although research has shown that, TCs are effective, like all other approaches to DAT service delivery, they are not 100% effective. This fact limits cost-effectiveness because relapse is related to increased criminal behavior and the cost of re-treatment. It is now time for NIDA to shift its focus to identifying ways to help TCs increase their effectiveness. This conference was intended to establish a new direction for TC research that will be set in partnership by both practitioners and the research community. To that end, conference participation was evenly split between leaders in the field of research and TC DAT services. The conference was organized to address four areas:

• State of the Science in Therapeutic Community research
• Research in the TC: Provider and researcher perspectives
• TC program and provider research issues
• New directions for research in TCs

Need to Take Research to the Next Level

Dr. Alan Leshner, NIDA's director, asserted that the research of tomorrow cannot be satisfied with continuing to demonstrate that DAT works. The challenge for our future lies in learning how it works, why it works, and how to make it better and more affordable. NIDA needs to move beyond studies that take DAT research to the next step. It must make bold leaps forward to take research to the next level, a level that will promote significant improvements over current treatment practices. To do this, NIDA and its funded researchers must build a partnership with TC practitioners to forge an alliance that will improve the quality of scientific study, while at the same time, enlighten TC treatment and service delivery.

Need for Research-Practice Partnership

Kevin McEneaney, President of the Therapeutic Communities of America spoke cogently for TCs to open their doors to welcome researchers into their programs in order to study DAT and the TC process. He described a collaborative process that directly involved TC service delivery leaders in defining the research questions of tomorrow. Although in the early years, many TC administrators did not understand the value of allowing researchers to study their treatments and methods, the TC field has progressed to a point that its growth and development requires reliable and valid information to guide policies and practices in an era of increasing public accountability for the investment of public health dollars.

State of the Art

Dr. George De Leon, Director of the Center for Therapeutic Community Research at the National Development and Research Institutes in New York City is one of the Nation's foremost experts on TCs. Dr. De Leon presented an overview of the state of the science in TC research during NIDA's 25-year history. He pointed out in his recent book, "Therapeutic Communities," that despite decades of research examining TCs very little is understood about the TC process. He asserted that there was a broad spectrum of programs claiming that they provide TC services. However, some of these programs may be quite far from the mainstream service delivery practice. Research that compares TCs to one another or other treatment approaches may be disadvantaged by inconsistent adherence to a common service delivery model, what De Leon calls the "classic TC model." Dr. De Leon pointed to the need for research aimed at learning how many different types of TCs there may be in common use today, what, if any core processes and practices they share, and how the various TC models differ in terms of participant outcomes.

The Provider Perspective

Dr. David Deitch, Director of the Pacific Southwest Addiction Technology Transfer Center at the University of California in San Diego spoke compellingly for more and better quality research in TC settings. Dr. Deitch, like Dr. De Leon, has spent virtually his entire career in DAT research and practice, much of in TC settings. Dr. Deitch reminded the audience that inquiries about TCs often elicit similar reactions to those people have to the Bible. Like the bible, the TC is many different things to many different people. TCs have worked hard to develop a unique niche in DAT service delivery. However, over time practices have not been codified, resulting in uneven application of methods, and/or have been modified in some instances to cope with changes in financial support and/or special settings such as jails and prisons. Even today, some TC adherents refer to their style of service delivery as a "movement." The historical evolution of TCs has colored provider approaches to learning. In some cases, this has resulted in clinical staff trusting personal experiences with addiction, TC recovery, and its treatment over reliable clinical diagnostic information. Research is needed to examine ways to ensure that reliable and high quality practices are applied in TCs, and strategies to change established values and beliefs that are barriers to improving TC service delivery.

The Researcher Perspective

Dr. Nancy Jainchill and Dr. James Inciardi each discussed issues related to TC treatment involving special populations and special settings. Dr. Jainchill, who is Deputy Director of the Center for Therapeutic Community Research at the National Development and Research Institutes in New York City pointed out how persons with special needs (special populations) have been merged on a conceptual level with subpopulations (referring to common racial, age or other characteristics), yet these distinctions are important to interpreting research outcomes. Dr. Jainchill's research on adolescent DAT has shown that adults respond quite differently from adolescents to certain aspects of the TC process. For example, for adults, successful recovery is strongly related to retention in treatment beyond a minimum of 90 days. High motivation for recovery is correlated with treatment retention for adults but to a far less extent for adolescents. Moreover, retention in treatment among adolescents does not demonstrate the same strong relationship with outcomes found for adults. Dr. Jainchill called for more research addressing how to apply TC practices in ways that produce consistent outcomes across both subpopulations and participants with special needs.

Dr. Inciardi described the special challenges of doing research in criminal justice settings. For example, staff turnover disrupts continuity of care and draws on clinic resources to recruit, hire, and train replacement staff. He and Dr. Deitch pointed out that because of the remote location of many prisons, attracting and keeping quality staff becomes a challenge after the first year of operation. An additional area for research called for by Inciardi is better understanding the relationship between treatment providers and the organizations and systems that administer sentencing, prisons, and parole to ensure appropriate continuity of care during and after release. Dr. Inciardi presented follow-up results for the Delaware Corrections-Based TC showing significant improvement trends for participants in prison TC who received full continuity of care.

A variety of TC-related research questions were discussed and examined in open forum lead by two TC directors: Richard Pruss, Treasurer of the World Federation of TCs, and Michael Harle, 2nd vice President; Therapeutic Communities of America; and two TC researchers: Dr. David Deitch, UC San Diego, and Dr. James Inciardi, University of Delaware. Questions fell into one of four general topic areas: the treatment process, client and staff issues, special populations, and service improvement.

Treatment Process

• How does financing affect clinical decisions?
• How do we measure peer influence?
• How do we measure the impact of group therapy?
• How do various therapeutic interventions maximize outcome at the different phases of treatment?
• How can the bond (group transference) to the TC be strengthened, particularly within the earliest stage of treatment?
• What is the optimum frequency of component interventions (e.g. how many encounter groups per week)?
• How and why is confrontation critical to the TC? How is it maximally applied? What are the results of its proper and improper implementation?

Clients and Staff Issues

• What is the best background mix and ratio of staff relative to clients?
• What is the profile of a successful person in treatment?
• What organizational or structural changes could be developed to enhance client motivation and retention in treatment?

Special Populations

• What modifications are needed to treat special populations in special settings?
• How can comprehensive services (legal, medical, vocational, educational, etc) be provided while maintaining the integrity and strength of the TC model and method?
• For special populations (e.g. mentally ill chemical abuser (MICA) clients, adolescents), what adaptations are necessary to improve retention and outcome? How can such adaptations be implemented without sacrificing the essential components of the model?
• Are there differences in the ways in which women engage in and benefit from TC treatment?
• What additional services should be consistently brought to women in TCs (e.g. victims of abuse groups, parenting skills groups)?

Service Improvement

• How can technology be used to improve treatment effectiveness and efficiency?
• How can transition to re-entry and aftercare in the community be facilitated and strengthened?
• How can TCs incorporate and measure the impact and effectiveness of new interventions and techniques from related fields?

All participants seemed to agree that a partnership between researchers and practitioners was an important goal in helping to better understand TCs and how to address their unique problems.

Systems Perspective

Dr. D. Dwayne Simpson, Director of the Institute of Behavioral Research at Texas Christian University (IBR, TCU), presented a paradigm for studying TCs systemically. He pointed out that although long-term follow-up studies help to determine the effectiveness of treatment programs, they do not inform practitioners about how to improve service delivery processes. Even complex relationships, previously thought to be beyond the reach of behavioral science study in TCs, are possible. Using research from the NIDA-sponsored Drug Abuse Treatment Outcomes Study (DATOS) and other research projects over IBR's long history in drug abuse research, Dr. Simpson showed the power and flexibility of structural equation modeling for addressing complex process issues among many diverse variables. For example, he showed that long-term residential treatment programs with the lowest participant retention rates also had the most "troubled" caseloads. However, participant factors did not account for all the variance between residential treatment outcomes. Differences in motivation levels, rapport with staff members, counselor skill levels, family support, and continuity of care all played a significant role in treatment success. Dr. Simpson concluded that unique TC processes can be studied by modern statistical models.

Measurement Perspective

Dr. David Kressel, a senior researcher at NDRI in New York City, built on Dr. Simpson's presentation. He outlined a variety of scientific instruments shown to validly measure many of the variables considered important to the study of TCs. Included were measures of agency organizational and structural factors, tracking resident movement through treatment stages, as well as dynamic client characteristics and experiences. Dr. Kressel showed how these could me assembled to examine treatment processes in TCs. He stressed the need for regular measures of treatment fidelity as a means of (a) ensuring a reliable treatment effect for TC participants, and (b) providing reliable measures of TC treatment components for studying their relative contribution to outcomes. Dr. Audrey Burnam of Rand Corporation in New York City elaborated on presentations by Kressel and Simpson by discussing her experiences conducting research in New York's' Phoenix House. Her presentation emphasized how partnership between Rand researchers and Phoenix House management and staff helped ensure quality research and helped practitioners to improve. Dr. Burnam described the development of new measures that were less intrusive than many tools used in the past, yet still offered valid and reliable measurement.

Paradigm Options

A Social Psychology Perspective

Many who have written about TCs have emphasized the importance of group dynamics in the therapeutic process. The editor of the journal "Group Dynamics," Dr. Donelson Forsythe at Virginia Commonwealth University in Richmond presented how social psychology models could be applied to the study of TC processes. Although admittedly not a drug researcher, the ideas Forsythe presented clearly resonated with conference participants. He pointed out that therapeutic change has been shown to be largely sociogenic in origin. Social Psychology offers a variety of methods and theoretical frameworks for studying social influence in groups and how groups form member identity. He introduce three major group influence factors: informational, normative, and interpersonal influence, and asserted that these factors combine to create a potent, yet understudied force in therapeutic change within TCs.

A Treatment Environmental Perspective

The importance of studying the role of treatment environment was convincingly established by Drs. Christine Timko (Deputy Director) and Rudolph Moos (Director) from the Center for Health Care Evaluation at the Veterans Health Care System in Palo Alto at the Stanford University Medical Centers. Dr. Moos has published several books demonstrating the powerful influence that the treatment environment has on the recovery of people with drug, alcohol, and psychiatric problems both in outpatient and inpatient settings. Timko showed that each treatment environment is unique by presenting a comparison between drug abuse and psychiatric programs at the Stanford VA. The measures used in her example have been validated in a broad variety of program settings, and offer TCs a well-established metric for examining how TC environments may differ on a variety of important factors. Dr. Timko also stressed the need for more research examining the effect of the treatment environment on treatment staff Ð the environment as workplace. Considerable organizational research has been amassed to show that staff morale, performance, and turnover are related to environmental factors.

The second day of the conference opened with a seminar chaired by Dr. Dwayne Simpson at TCU, which addressed topics related to the role of behavioral treatments in TC settings.

Studying Drug Addiction as a Chronic Illness

Dr. A. Thomas McLellan from the Drug Abuse Treatment Evaluation Center of the University of Pennsylvania at VA Medical Center introduced the notion of treating substance abuse as a chronic disease. He presented evidence that compliance with medication and lifestyle changes were similar for drug abuse, diabetes, and heart disease. He debunked arguments that "drug abuse is different" because it is volitional by pointing out that most people know if they are at risk of chronic disease, yet they knowingly engage in behaviors that put them at high risk of serious illness (e.g., smoking, not exercising, over eating). Dr. McLellan pointed out the readmission rates for these chronic diseases are about the same in frequency and periodicity as for drug abuse relapse. He suggested that TCs begin to apply this perspective to studying ways to treat drug addiction.

Building Bridges Between Providers and Scientists

Professor Marsha Linehan from the University of Washington at Seattle focused her presentation on overcoming barriers to treatment-practice partnership. She acknowledged that the professional interests and reward systems for researchers and practitioners were quite different. Nevertheless, both groups benefit from their cooperation. Researchers create new knowledge for the scientific community, and practitioners have hard date that can be used to support their decision-making. In many cases, having data can justify resource allocations and improve the quality and efficiency of treatments. This is particularly true for TC DAT services, which are largely behavioral, and therefore more challenging to validate.

Questions to Consider

Drs. Edward "Ned" Nunes from the New York State Psychiatric Institute and Varda Shoham, Director of the Clinical Psychology Program at the University of Arizona in Tucson discussed design and paradigmatic issues surrounding studying the efficacy of new behavioral treatments in a TC setting. Dr. Nunes emphasized the value of conducting randomized trials in TC settings. Acknowledging that this is difficult, Dr. Nunes pointed out that without studies applying such scientific rigor, there will always be a large number of skeptics in the medical and political communities who are used to relying upon validations conducted under such conditions. Moreover, randomized control will eliminate threats to valid inference currently confounded by self-referral effects, coercive referral (e.g., MICA and criminal justice clients). Perhaps most importantly, randomized trials will enable manipulation of key treatment elements in ways that will enable quantification of their contribution to therapeutic outcomes. Dr. Shoham emphasized the importance of looking outside the TC to examine how participants' social and support networks interact to affect TC outcomes. She also called attention to the need for researchers to examine experimentally the role of social confrontation, isolation from outside social influences, and the amount of coercion used to develop behavioral changes as these can affect retention in treatment, which is relatively low for most TCs.

At the end of the conference, participants had the option of attending any of four working break-out groups to discuss new directions for TC research in light of the conference presentations and discussions. The working group topics included:

• TC environments and treatment systems
• Organizational factors and TC practices
• Treating special populations
• Studying TC treatment processes

Each group included at least four presenters who addressed topics relevant to the working group topic. Final reports from the groups merely reiterated earlier suggestions from presenters and participant commentary. It is noteworthy, however, that a large percentage of discussion time was devoted to the topic of building rapport, if not rapprochement between researcher and providers. Researchers expressed concern that TCs would not cooperate with the necessary restrictions needed to comply with scientific protocols. Providers countered with concerns about the benefits to their organizations of accommodating to research activities. Nevertheless, both parties expressed confidence that progress had been made in building a cooperative alliance between research and practice in TC settings. Leaders at both NIDA and TCA agreed to meet before the end of the month to discuss concrete steps to promote future research in therapeutic communities.