Evidence Supporting the TC Approach

[A] TC is often the last option for treatment chosen by drug users. This results in a client population with entrenched drug use histories who are often intransigent and difficult to engage in treatment (Gowing et al, 2002: 1).

Consultation with the Australasian TC sector suggests that TCs are effective for individuals that have tried a range of treatment approaches and have not got what they need from it, have a long history of dependence or a severity of dependence, and have a range of complex issues beyond their drug use. This is not to say that TCs are not effective for less complex individuals.  Research on TCs or services offered in residential settings compared with medical model treatments is limited however what there is supports some of the practice wisdom of the sector.

Marsh et al (2007: p 30 – 31) provides a range of sources that supports evidence for treatment in residential settings and/or TCs:

  • Treatment in a residential setting is evidenced as appropriate for alcohol dependence where the client is a chronic drinker with a long history of drinking and a high level of dependence (Eliany & Rush 1992: Project MATCH Research Group 1998)
  • TC treatment is also evidenced as effective for alcohol dependent clients who have social networks that support continued drinking (Project MATCH Research Group 1998)
  • Treatment in residential settings is recommended if social factors do not support abstinence and for individuals considered high risk (Melnick et al, 2001)
  • Treatment in residential settings is recommended for individuals that have few skills for earning a living (Melnick et al, 2001).
  • Modifications that support specific population groups improves retention (De Leon, 2000)
  • The effectiveness of residential TC programs is improved when a broad range of interventions (multidimensional elements) are incorporated into the program (Gerstein & Harwood, 1990; Moore, 1998; Timko et al, 2000). This is likely to be as a result of the varied interests that can be maintained and therefore the level of ongoing satisfaction and motivation, and the multifaceted results that become evident through participation that potentially restore faith in the future.
  • The duration of treatment is a contributing factor to the efficacy of treatment outcomes, i.e. longer programs (three to twelve months) are associated with better outcomes (Broekaert, 2006; Gossop, 2003; Hser et al, 2004; Moos et al, 1999; Zhang et al, 2003).

The TC Sector

While the Australasian TC sector is informed by a model, and has had Essential Elements (the ATCEEs) to inform its practice since 2002, it remains a diverse and vibrant sector. The sector is made up of, for example:

  • Non-government and government managed TCs
  • Organisations where the TC is their primary service, compared with others where the TC service makes up only a component of the overall services
  • Organisations that have a single TC, compared with others that have multiple TCs either in different locations or to meet the needs of different population groups
  • TCs that are modified to meet the needs of specific population groups. For example there are mixed gender TCs, and TCs specifically designed for men or women only. There are TCs that are specifically designed for Indigenous peoples, parents (women, single parent or couples) with young children, youth/adolescents, or people with co-occurring mental health and alcohol and other drug issues, etc
  • TCs that are strictly abstinence based and others that support people on opiate replacement pharmacotherapy
  • TCs that are 3 months duration through to others that are over twelve months duration
  • TCs linked to half-way houses as a re-entry option or offer other aftercare options
  • TCs located in inner-city locations, outer metropolitan locations, regionally based
  • Community based TCs and prison based TCs
  • TCs with less than twenty through to more than a hundred bed capacity.

In general TCs in Australia and New Zealand are modified to meet the specific needs of the people that access their service. The governance structure overseeing the TC may differ between organisations. The location of the TC will impact on the required or available partnerships that are needed to support capacity building. The location may also impact on the capacity of the TC to recruit and retain staff. Given all of these differences there is a strong and enduring commitment to the TC model.

What sets the TC sector aside from many other sectors is the solidarity and support that different organisations have offered each other over the years. This is supported to a large degree by the Australasian Therapeutic Communities Association (ATCA), which provides networking opportunities, supports sharing of information, offers an annual conference typically with international presenters, and lobbies on behalf of the TC sector. The ATCA Board has representatives from across Australia and New Zealand, and from a diverse range of TCs. The number of services that identify as TCs that come under ATCA’s membership is currently more than 50.

TCs, as per residential rehabilitation services, require a sustained resource commitment from government funding bodies. That the number and size of TCs has steadily grown over the years is a clear demonstration of this commitment. Presenting a nationally and internationally structure model supports confidence in the service approach, from funding bodies and other key stakeholders.

Contribution to AOD and TC Sector Research

Evidence shows that harm minimisation approaches and programs are more effective than ‘tough on drugs’ policies (factsheet from www.communitylaw.org.au).

Research estimates the benefits of treatment to outweigh the costs by four to one (cited from Harwood et al. (1988), cited in ADCA drug action week treatment flier). In the US, every dollar spent on drug and alcohol treatment saves the public seven dollars, mostly through reductions in crime and the need for medical care (cited from Gerstein et al. 1994, ADCA drug action week treatment flier), while in the UK figures show a £3-18 saving in criminal justice and social costs for every pound invested in treatment (cited from Roberts M. et al. 2006 Monitoring drug policy outcomes: the measurement of drug-related harm , The Beckley Foundation Drug Policy Program).

Other research shows that twelve months after treatment, an individuals’ drug use could be halved, criminal activity reduced by up to 77%, and employment, housing, physical and mental health improved (cited from Centre for Substance Abuse Treatment 1996, ADCA drug action week treatment flier).

Pitts (2009) concludes:

The therapeutic community residential treatment model has been shown to be effective in the treatment of persons with alcohol and other drugs problems.  Persons who have high rates of daily drug usage and higher rates of participating in criminal activity to support their use of drugs are prominently featured within the therapeutic community sample. These two indices can have a negative correlation to positive treatment outcomes and thus this population is a challenge to therapeutic community clinicians as they are truly involuntary clients.

In spite of this difficult population therapeutic communities have provided an environment whereby individual correlates of compulsive/intensive/dependent use of substances are well documented and recognised:  a link to intensified criminal activity; loss of employment and unemployability; deteriorated interpersonal relationships; and a focus on drug seeking and using activities and peers.  The therapeutic community can assist an individual to process, deal with, and work through many of these issues in a safe environment and promote the acquisition of more adaptive coping skills.

The cost benefits of treatment have been shown to have ratios of from 4:1 to 12:1, depending on the treatment modality.  Within this context therapeutic communities have demonstrated costs benefits equal, to and in some cases, superior to other treatment interventions…

Therapeutic communities provide substantial costs benefits to the community and the residents who utilise their services.  Not only are the cost benefits substantial, but gains are made in other domains as well…. Most importantly, when residents are in treatment they stay alive!

Participation in research was highlighted as desirable by the Australasian TC sector in order to build the evidence base of the TC approach. The sector was, however, realistic about the resource requirements to do this. A cost effective approach, which has been adopted by many TCs, is to work collaboratively or to share research results.

In general TCs recognised an increasing need for the evaluation of their services. This was often expressed in consultation with service representatives as a collective need for the TC sector, including the establishment of a set of consumer outcomes resulting from participation in a TC with outcomes measures for the range of benefits TCs offer. Outcome measures that are anecdotally recognised and yet not demonstrated by research include:

  • Securing accommodation
  • Improved relationships
  • Reduced criminal activity
  • Effective post-prison integration
  • Improved health
  • Education and vocational development
  • Improved functionality generally
  • Reduced drug use harm.

The appreciation that not all TCs are the same, for example, providing a service to different population groups where outcome measures may be impacted by contextual considerations, was expressed. Any collective collation of such information would need to take this into consideration and would not be used to draw comparisons between services. A number of TCs currently have partnerships with research bodies, and input from such experts is seen as necessary to inform evaluation processes.

A number of formal evaluations of TCs have been undertaken, including an evaluation of: Karralika in the ACT (National Campaign Against Drug Abuse, 1987); Odyssey House Victoria (The University of Melbourne, 1994); the Woolshed in SA (National Drug and Alcohol Research Centre, 1998); etc.

Collaborative research projects that have occurred in the TC sector over the past few years include:

  • The development of the Australasian TC Essential Elements (Gowing et al, 2002).
  • Cost Benefits of Therapeutic Community Programming: Results from a national survey – presented at the World Federation of Therapeutic Communities Conference 2002, and Cost Benefits of Therapeutic Community Programming: Results of an updated survey – presented at the European Federation of Therapeutic Communities Conference 2009 (James Pitts, Chief Executive Officer Odyssey House McGrath Foundaton NSW).
  • Staff training needs to work with residents who have a diagnosis of Personality Disorder – research in three TCs (Stephanie Stace, 2007).
  • The development of treatment protocols for working in TCs with people who have problems with amphetamine use (Odyssey Sydney, not yet published).
  • The development of Australasian AOD TC Standards (ATCA, 2009).

These and many other research projects have or will benefit Australasian TCs specifically.

This information is from the ATCA Standards and the ATCA Standards Support Package written by Jill Rundle and funded by the Australian Government Department of Health and Ageing.  As per the copyright, this information has been reproduced for the purpose of supporting the quality processes of Cyrenian House, an ATCA member organisation and to further promote community understanding with regard to the TC Model.

References:

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

Gowing L., Cooke R., Biven A., Watts D. (2002) Towards Better Practice in Therapeutic Communities. Sydney: Australasian Therapeutic Communities Association.

Marsh A., Dale A., Willis L. (2007) Evidence Based Practice Indicators for Alcohol and Other Drug Interventions: Literature Review, 2nd ed. Perth, WA: Drug and Alcohol Office.

Mattick RP., O’Brien S., Dodding J. (1998) Outcome Evaluation of the Woolshed Program. National Drug Research Centre, University of New South Wales.

Pitts J. (2002) Cost Benefits of Therapeutic Community Programming: Results from a national survey. Odyssey House McGrath Foundation. Presentation at the World Federation of Therapeutic Communities, 2002

Pitts J. (2009) Cost Benefits of Therapeutic Community Programming: Results of an updated survey. Odyssey House McGrath Foundation. Presentation at the European Federation of Therapeutic Communities, 2009

Stace S. (2007) Staff training needs to work with residents who have a diagnosis of Personality Disorder – research in three TCs. Study paper: University of Griffith.

Toumbourou JW., Hamilton M., Fallon B., Scott J., Skalls W. (1994) Out of Harms Reach: An evaluation of the effectiveness of different levels of treatment at Odyssey House. Department of Public Health and Community Medicine, University of Melbourne.