As the demographics of people seeking treatment for substance use disorders (SUDs) have shifted, therapeutic community (TC) programs have adjusted to respond to participants’ needs (De Leon, 2012). Today’s TCs involve people with co-occurring mental health problems, youth (both those who are involved in the juvenile justice system and those who are not), individuals who are homeless, and those in the criminal justice system. During the 1990s, some organizations developed modified TCs that were at the forefront of addressing the special needs of these populations (Sacks et al., 2004a; Sacks et al., 2004b; Sacks & Sacks, 2010; Jainchill et al., 2005).
People with psychiatric comorbidities
Survey research suggests that 50 to 70 percent of participants in substance abuse treatment have more than one SUD and at least one other psychiatric disorder (Dye et al., 2012). Historically, substance abuse treatment has often failed to address these co-occurring disorders. However, increasing recognition of the high prevalence of psychiatric comorbidities among those with SUDs (and vice versa) and evidence that people with comorbidities have worse outcomes (Van Stelle et al., 2004) have prompted more addiction treatment organizations to address these co-occurring problems with integrated care (Sacks & Sacks, 2010; Sacks et al., 2008a; Perfas & Spross, 2007).
TCs for individuals with co-occurring substance use and mental disorders are designed for participants with the most severe mental illnesses—schizophrenia and other psychotic disorders, bipolar disorders, and major depression (Sacks & Sacks, 2010). The current standard of care is to treat substance use and mental health disorders simultaneously, and many TCs offer mental health services on-site. Program participants are taught about mental illness, how it influences substance use and dependence, the process of simultaneous recovery from both substance use and mental disorders (dual recovery), and how to access mental health and social services in the community (Sacks et al., 2008a). Individuals receiving prescribed psychiatric medications are given the necessary monitoring and case management.
A review of four studies on TCs for people (902 in total) with co-occurring, mostly severe mental illnesses found that these individuals had better outcomes compared with those who received standard care, including greater improvements in substance use, mental health, crime, HIV risk, employment, and housing outcomes (Sacks et al., 2008a).
The problems of SUDs, mental illness, and homelessness often overlap. Some TCs have adjusted their programs to meet the particular needs of people who are homeless and have co-occurring mental and substance use disorders. These programs offer meetings and activities of shorter duration and provide more hands-on involvement from staff. Information about mental illness, SUDs, and other relevant topics is presented gradually and explained thoroughly, and there is a greater emphasis on assisting program participants (Skinner, 2005).
People with these co-occurring problems who had completed residential TC treatment (12 months, on average) in addition to aftercare in the form of a supportive-housing program with the TC approach showed better outcomes than those who did not participate in the housing program (Sacks et al., 2003). In supportive housing, people live in various community settings (group homes, apartments, and single rooms) and have access to counseling support and social services. Counselors provide assistance, conduct relapse-prevention groups, and offer individual therapy and case management; staff members help participants access day treatment, dual-recovery services, and self-help groups.
During residential TC treatment, homeless participants demonstrated reduced drug use and crime and maintained these gains during the supportive-housing aftercare program. Participants also showed steady improvements in psychological functioning and employment gains during both residential TC and aftercare and demonstrated significantly better outcomes than those who did not receive supportive housing (Sacks et al., 2003).
Women with SUDs have a higher risk of depression or other mental health disorders, low self-esteem, criminal involvement, homelessness, a history of trauma (including from sexual abuse, sexual assault, and domestic violence), involvement in the sex trade, and HIV than men with SUDs (Covington & Bloom, 2006; Cooperman et al., 2005). They may also have minimal access to much-needed medical, mental health, and social services and lack marketable job skills and family support (Covington & Bloom, 2006). Both substance abuse and homelessness can lead to loss of child custody (Sacks et al., 2004b), and women may be mandated by the court to receive treatment or voluntarily seek therapy in response to this possibility.
Women-only and mixed-gender TCs offer integrated mental health, substance abuse, educational, vocational, legal, and housing placement services that seek to address women’s complex needs. Such programs generally place less emphasis on confrontation as a therapeutic tool (Sacks et al., 2004b, 2012a); they usually also provide services such as child care or child development centers. Goals are established to specifically focus on the relationship between the mother and her children. This can include improving awareness of parenting behaviors, developing problem-solving skills, understanding developmental stages, enhancing communication and emotional expression with children, and improving skills to address children’s behavioral problems. For those who have lost child custody, staff work with the mother to prepare for family reunification, assist with arranging for visitation, and help with navigating the child protective services system (Stevens et al., 1997).
Women are also more likely to need therapy to address the multiple traumas, such as physical, sexual, and emotional abuse, that they have experienced (Sacks et al., 2004b). Seeking Safety, an evidence-based practice aimed at treating trauma-related problems and substance abuse, is implemented in some TCs. Women in such programs learn behavioral skills for coping with trauma and post-traumatic stress disorder. For example, lessons include how to set boundaries in relationships, engage in self-care, deal with emotional pain, and make healthier life choices.
As with men, women with SUDs are often incarcerated (see "How are Therapeutic Communities Integrated into the Criminal Justice System?"). Female inmates have higher rates of co-occurring mental disorders and exposure to physical and sexual abuse than their male counterparts (Sacks et al., 2012a). Prison is an opportunity to address their substance use and other behavioral problems (e.g., recovery from trauma, lack of employment skills, and need for parenting education) in a gender-sensitive way. In addition to standard TC components for offenders of both sexes, gender-sensitive therapeutic approaches for women inmates enhance understanding of female roles and relationships and how they tie in with drug use.
Women with SUDs who participated in gender-sensitive, prison-based TC treatment demonstrated significantly better drug use and criminal activity outcomes a year after release than those in a comparison group who received CBT (Sacks et al., 2012a). They also demonstrated reduced exposure to trauma, improvements in mental health functioning, and a longer time (20 days) until re-incarceration compared with those who received CBT. Another study of women mandated to a TC found that participants who completed treatment had reductions in various measures of substance use; decreased incidences of risky sexual behaviors associated with drug use (which increases risk for sexually transmitted diseases), such as unprotected sex, sex trade, and sex with multiple partners; and less reported relationship violence/conflict (Cooperman et al., 2005). A study of homeless women with SUDs and co-occurring disorders who participated in a TC for 12 months found improvement in mental health symptoms as well as better physical health. After a year of treatment in the TC, women assumed financial responsibility for more of their children compared with those who participated in a regular TC program (Sacks et al., 2004b).
Adolescence is a major window of vulnerability for trying drugs and developing SUDs. Most who develop an SUD start using substances by age 18 and develop their disorder by age 20 (Dennis et al., 2002). Most do not seek or receive treatment, however, and if they do, it is typically because they have been referred by the juvenile justice system.
The adolescent TC is a modification of the adult TC that addresses the specific needs of the adolescent participant, providing a comprehensive and "holistic" treatment approach that recognizes and attends to the developmental issues that adolescents face in treatment and in their daily lives. The adolescent TC is based on a self-help model that utilizes intense positive peer pressure, family involvement, an organized work structure, vocational/life-skills preparation, and individual introspection to challenge participants and equip them for a drug-free lifestyle (Jainchill, 1997; Jainchill et al., 2000; Edelen et al., 2007; Foster et al., 2010; Becan et al., 2015). Based on the outcomes of long-term efficacy studies with adolescents in TC settings, such programs now integrate evidence-based approaches—particularly motivational enhancement and trauma-informed care—as well as alternative therapeutic practices like art therapy, yoga, and meditation (Rivard et al., 2003; Hawke et al., 2003; Foster et al., 2010). The overall focus of this integrated interdisciplinary approach is to intervene in substance use and behavioral health disorders and to assist the adolescent in the successful mastery of significant developmental tasks.
Similar to the adult TC model, adolescent programs incorporate phases or levels of treatment and a sanctions-and-rewards system. In this system, participants earn status and privileges contingent on their progress toward meeting and exceeding treatment milestones (Jainchill et al., 2000). These programs incorporate family, vocational/educational, medical, and recreational services throughout treatment. Adolescent TCs also address co-occurring mental health disorders and factors leading to criminal activity that may have precipitated involvement with law enforcement and court systems. Adolescent substance users who are admitted to TC treatment typically have experienced a wide range of other life problems. These include psychological issues—such as depression, mood disorders, and violent tendencies—as well as poly-substance use and involvement with the juvenile justice system (Jainchill et al., 2000; Perry & Hedges Duroy, 2004). In light of this, the adolescent TC therapeutic process necessarily involves features that are distinct from those suitable for adults (Edelen et al., 2007).
A critical therapeutic objective in adolescent TCs is cognitive restructuring, a process of altering the attitudes that underlie antisocial, unhealthy behaviors—such as thinking that aggression is the only way to solve a problem or acting out to deal with difficulties—and replacing them with attitudes that support personal responsibility and pro-social behaviors (Jainchill et al., 2005). The integration of life-skills development (e.g., through participation in art therapy, vocational education, and a 12-step program) is paramount to accomplishing this, as these skills support pro-social adolescent development (Aromin et al., 2008).
As with any population and substance abuse treatment modality, enhancing motivation and retaining adolescents in TC programs is critical. In NIDA-supported research, six adolescent TCs assessed the effectiveness of the Treatment Readiness and Induction Program (TRIP) for increasing treatment motivation and, ultimately, retention (Becan et al., 2015). Findings suggested that TRIP directly increased adolescents’ problem recognition, which in turn increased the desire for help and treatment readiness—important aspects of therapeutic motivation.
Several studies have suggested that TCs are successful in reducing substance use and criminal behaviors common among the adolescents who participate in these programs (Jainchill et al., 2000; Morral et al., 2004; Perry & Hedges Duroy, 2004). In addition, TCs have been shown to help adolescents develop pro-social skills and learn to cope with family issues (Jainchill et al., 2005; Morral et al., 2004; Gordon et al., 2000).