Much has been written about the underlying principles of the therapeutic community (TC) drug abuse treatment model (e.g., [
1,
2]). Woodhams[
2] describes this model as one in which staff members interact with residents in an environment where "community as method" is the organizing principle. This community is assumed to be responsible for one another's treatment, having an equal role in the treatment process rather than staff bearing the primary responsibility for treatment. The staff role is to facilitate the implementation of TC principles by behavior modeling and to reinforce the community concepts and philosophy in the community's decision-making process. Staff and residents share the following concepts and beliefs:
▪ View of the disorder
Addiction problems are centered within the individual; physiological symptoms exhibited are secondary.
▪ View of the person
Treatment plans are individually tailored; however, addicts often share certain characteristics, such as low self-esteem, lack of impulse control, low tolerance for frustration, inability to cope with feelings, dishonesty, poor interpersonal skills, immaturity, and feelings of being a victim.
▪ View of recovery
Residents must learn experientially through feedback from encounter groups and interaction with other residents in the community to recognize and change negative behavior.
▪ View of right living
Residents are encouraged to adopt a philosophy that reinforces moral and ethical beliefs typically held by mainstream society rather then continuing to hold negative, self-serving views. Residents are encouraged to own their feelings and internalize pro-social feelings of doing what is right in a given situation.
In addition to clinical and administrative staff, TCs often employ staff members who are ex-users or graduates of a TC program[
2]. The recovering staff members are considered "rational authorities" who use their skills and experiences to guide, teach, coach, and correct negative behavior of clients[
3]. The role of the staff is to facilitate the development of clients' treatment plans by coaching, reinforcing corrective and positive behavior, clarifying issues, and lending assistance when needed. Staff interaction with drug addicts in a therapeutic community is more intense than in other treatment milieus; it is more frequent and can be more confrontational.
This article reviews the research on TC drug abuse treatment and training and presents results of a large TC drug treatment follow-up study in Peru. The study focuses on the treatment success of 33 treatment facilities in various locations of the country and predictors of treatment success. Multi-level analysis procedures were employed to take into consideration the bias due to the influence of a facility on all former clients from that facility. This sample of 33 facilities is a subsample of 72 TC facilities that were involved in a study of Daytop TC training impact on staff[
4]. The purpose of the current study is to ascertain changes in former clients' use of alcohol and other drugs after treatment in TC facilities and to determine whether predictors of client changes in alcohol and other drug use after treatment could be identified. Evaluation of drug treatment effects in developing countries is scarce. This study is one of the first studies to document what happens to former clients after drug treatment in a developing country.
Studies of TC drug abuse treatment effects on client behavior
Over the past 30 years an unprecedented number of applied addiction treatment outcome studies have been conducted. Major catalysts for this research have been the National Institute on Drug Abuse (NIDA) national research programs: Drug Abuse Reporting Program (DARP) in the 1970s[
5,
6]; Treatment Outcome Prospective Study (TOPS) a decade later[
7]; in the 1990s, the Drug Abuse Treatment Outcome Studies (DATOS)[
8,
9]; and the National Treatment Outcome Research Study (NTORS)[
10]. A consistent body of research has supported the effectiveness of drug treatment in general (e.g., [
9]) and of TCs in particular[
11,
12].
Criticisms of drug treatment outcome studies have pointed to methodological shortcomings that investigators regularly debate. In a review of drug treatment outcome methodology reported in peer-reviewed journals between 1993 and 1997, Ellingstad and colleagues[
13] found that less than one-fourth of the articles used a minimum six-month follow-up interval, which is an important consideration because the highest period of relapse has been found to be between three and six months following treatment[
14].
Client outcome studies of the therapeutic community model have focused on specific target populations that the programs are intended to serve (e.g., prison or jail inmates, chronically homeless drug or alcohol abusers, youth/adults in the general population with chronic and debilitating drug/alcohol problems, dual diagnoses of mental illness and drug addiction) and have employed a variety of methodologies (pre, post tests, single case study, comparative studies, etc.). The outcomes that are typically measured are related to the most serious problems associated with these groups (e.g., re-arrest or reconviction rates, unstable living arrangements and employment, lack of reduction or abstinence from drugs or alcohol use).
The single case study method has often been used to examine outcomes of TC treatment clients in a particular program. For example, Wilson and Mandelbrote[
15] examined reconviction rates of ex-residents of the Ley Community TC in Oxford, England, and found correlations with historical patterns of criminal behavior, prior drug use, and length of duration in the program. The authors concluded that TC treatment is effective in reducing criminal activity for residents who stay in the program longer than six months. Holland[
16,
17] found similar results for residents of the Gateway House in Illinois. In a five-year follow-up study of ex-residents of the Phoenix House program in New York, De Leon[
18] also found improvements related to duration in the program. Dekel and colleagues[
19] found that fifteen months after leaving the TC program, half of the Israeli heroin addict participants were clean. Those who had lived with a partner before entering the TC and those who had not engaged in theft prior to treatment were more likely to be drug free at follow-up. A 12-month follow-up study of 83 graduates from community-based TC programs found the majority of participants reported being free from alcohol- and illegal drug use as well as experiencing improvements in the areas of employment, living arrangements, family relationships and high-risk negative behaviors[
20].
Using a pre- and post-test design, De Leon[
21] found that both graduates and dropouts of the Phoenix House program improved significantly on measures of personality disorder and self-esteem at the two-year follow-up but client improvements were still below the "normative" or healthy range. Ravndal[
22] collected pre and post data from program applicants, dropouts, and completers of a Phoenix House program in Oslo, Norway, and found that completers had fewer substance abuse problems and better social functioning outcomes at the five-year follow-up than those who never entered or dropped out of the program. Those reporting lower frequency of drug use before applying or entering the program had higher rates of success at the five-year follow-up. In a 12-month follow-up of 83 (70%) graduates of inner-city TC programs, researchers found the majority still abstaining from drug and alcohol use, and experiencing improvements in employment, living arrangements, family relations, criminal and other high-risk negative behavior[
20]. In a comparative study of two TCs and two no-treatment groups in the Netherlands, Kooyman[
23] found much better outcomes for the TC clients at six-month follow-up. De Leon and colleagues[
24] found greater behavioral improvements at the 12-month follow-up among homeless, mentally ill chemical abusers in two modified TC programs than those assigned to the control group.
Predictors of favorable treatment outcomes
Studies have consistently shown the length of time a drug user stays in a treatment program is one of the most important predictors of successful treatment outcomes[
25,
26,
11,
27,
28]. The effectiveness of treatment programs is limited by the TC's ability to retain the clients for a period long enough to promote change. Typically, relatively few stay beyond three months[
29]. Early treatment follow-up studies [
30‐
32] found that successful client outcomes related to reduced crime and substance use and increased employment were related to time spent in treatment. Gossop and colleagues[
33] reported that critical time in treatment (28 days for shorter in-patient programs and 90 days for longer-stay rehabilitation programs) was strongly correlated with improvement in overall drug use, and that those who stay in the programs past the critical times were more than five times as likely to have achieved abstinence from all target drugs at the one-year follow-up than those who left. In a comparison of standard and abbreviated treatment in a TC treatment, De Leon[
25] and Nemes and colleagues[
34] found that positive outcomes are associated with "graduation" or completion of the entire treatment regimen, regardless of the length of the program. Toumbourou and colleagues[
35] concluded that attainment of level progress is a better predictor of treatment outcomes.
Chan and colleagues[
36] found that treatment satisfaction is related to pre-treatment problem severity and duration of treatment. More recent studies have found that program dropouts are more likely to have had conflicts with the program's rules and view the program as punishment, while completers tend to view the program as treatment and have more positive evaluations of staff[
37‐
39]. Further, Carlson and Gabriel[
40] found that client satisfaction with access and effectiveness was associated with six-month follow-up service utilization, as well as one-year post-treatment abstinence from drugs. Kasarabada and colleagues[
41] found that only two perceived characteristics of therapists, nurturance and openness, showed significant correlations with length of stay in treatment. However, positive perceptions of counselors had no significant effect on reducing drug use severity scores at a one-year follow-up.
The extent to which a program adapts the ideal TC model and its essential elements, and how staff actually implements the model, has been of interest to investigators (e.g., [
42,
43]). Some attention, although limited, has been given to defining program fidelity operationally. Prendergast and colleagues[
44] found in a meta-analysis study that well-implemented TC drug abuse treatment and outpatient drug-free programs were correlated with more positive behavioral outcomes. A number of studies have found positive direct effects of the quality and quantity of program implementation on drug-related outcomes [
45‐
48]. Hansen and colleagues[
49] found program fidelity to be a moderator of substance abuse prevention program effectiveness.
Some TCs provide additional staff training and education to build both staff skills in group dynamics and understanding of TC philosophy and ethos[
2]. Mistral and colleagues[
50] found that applying the principles of the therapeutic community to a high-care psychiatric ward did improve staff communication and staff attitudes. Focus groups with TC staff revealed that even after training on TC theory, methods, and procedures, staff have a vague idea about their roles and responsibilities in a TC setting and felt that experiential learning is important in working with drug addicts[
51].
In a study of the impact of staff training to implementing structural family therapy in an adolescent therapeutic community, Weidman[
52] concluded that increased staff confidence and competence may result in fewer dropouts and increased attendance in family therapy. Johnson, Young, Suresh, and Berbaum[
4] conducted a three-year intervention study using a social policy experiment design that employed a randomized design with repeated measures to test hypotheses about the effects of TC training conducted in Peru. The study tested for the direct and moderating effects of the training, examined implementation fidelity, and reexamined the underlying theory of the TC training model. The study found that the vast majority of the staff participants reported positive appraisals of the quality of trainers (e.g., trainers explained things), the quality of training content and methods (e.g., training handouts were helpful), the quality of training environment (e.g., training rooms and facilities were comfortable and convenient), and cultural sensitivity (e.g., cultural issues were handled with respect). The researchers concluded that the quality of training implementation was judged as more than adequate since
a priori expectations, as set by the trainers, were exceeded for all appraisal criteria. Further, the study found that the training had medium effects on staff behavior outcomes such as implementation fidelity of TC tools and small effects on staff empowerment to use TC methods and tools and actual use of TC principles.
McMillin[
53] reports many former drug addicts feel shame and guilt years after their last drink or drug use. He further states that stigma is a primary obstacle to solving our nation's alcohol and drug problems. A few studies have looked at the impact of stigmatization on drug use and treatment. Furst and colleagues[
54] suggest that the shame and stigma associated with the label "crackhead" served as a deterrent to potential adolescent users. Falck and colleagues[
55] found that stigma associated with cocaine use can serve as a barrier to treatment and use of clinical and non-clinical services. In a study of the relationship between methamphetamine use and depression, Semple and colleagues[
56] found that perceived stigma had a significant positive direct effect on depressive symptoms above and beyond that accounted for by methamphetamine use. Although we could find no studies that examined the relationship between outcomes of TC clients and their perception of social "stigma," studies of patients in mental hospitals have suggested that labeling and social stigma are related to treatment outcome variables such as self-esteem, employment status and social networks[
57,
58]. Room[
59] advocates for both quantitative and qualitative studies that examine potential preventive effects of stigmatization.
Therapeutic communities in Peru and treatment outcomes
As in most developing countries of the world, drug addiction is a serious social problem in Peru[
60]. Beginning in the mid-1970s, the United Nations Fund for Drug Abuse Control (UNFDAC) received contributions from the Government of Italy to establish Therapeutic Community (TC) treatment centers throughout Peru. Although a network of TCs were subsequently created in Peru and other South American countries by UNFDAC, treatment reports (outcome evaluations, etc.) in Latin America were scarce, mainly focusing on epidemiological studies[
61]. Furthermore, there were no systematic treatment reports in the Peruvian literature, and the initial papers only addressed treatment guidelines[
61]. Beginning in 1978, Navarro[
62,
63] described the treatment and follow-up of only two patients dependent on coca paste; both patients subsequently stopped using the drug. In 1980, Sanchez[
64] published a study on the treatment of 50 drug addicts at the Nana TC center in Lima, of which 15 addicts eventually became abstinent. Several years later, Navarro and colleagues[
65] conducted a study on 26 clinical patients at Nana TC who were followed-up from 8 months to 4 years after treatment. From 1982 through 1989, Navarro[
61] conducted a larger study of 223 male patients of the Nana TC, who were mainly consumers of coca paste. Over 47 percent were abstinent at follow-up.
Although UNFDAC had assisted in the creation of a network of TCs in Peru, the Peruvian government determined in 1997 that many of these programs were poorly trained, providing inadequate services, and needed to be licensed by the government. In 1997, this urgent need for TC drug abuse treatment training prompted the Peruvian government to make a strong appeal to the United States government for training support. As a result, the U.S. Department of State contracted with Daytop Village, Inc. to conduct extensive drug-free treatment training in Peru that included staff TC drug treatment institutional providers. This training was conducted in Lima, Peru. An extensive evaluation of this training was also conducted and was briefly described earlier[
4].
The TC drug abuse treatment follow-up study presented below is an extension of the Johnson and colleagues[
4] study described ealier[
4]. Three research questions are posed for this follow-up study.
Question 1. What are the overall changes in illegal drug and alcohol use (to intoxication) of former clients of TC drug abuse treatment facilities in Peru?
Question 2. What are the predictors (treatment processes, capacity-building training exposure, and organizational/client characteristics) of illegal drug and alcohol to intoxication use among former TC drug treatment clients?
Question 3. Are the predictors (identified in question 2) moderated by contextual variables?