Which of the following is not a therapy that utilizes the attitudes-follow-behavior principle?

Therapeutic Communities

Therapeutic communities are one of the more common treatment methods present in community programs and have been included in large-scale studies such as the Drug Abuse Reporting Program.78 Therapeutic communities are long-term, residential programs that utilize a social treatment approach. Therapeutic communities view drug abuse as a disorder of the person and the recovery process as development and integration of both psychological and social goals.80 The community as a group aspect of treatment is seen as the major impetus toward growth and change. The community is made up of the social environment, peers, and staff, many of whom are successfully recovered addicts themselves.18

Both behavioral and social learning principles are utilized in therapeutic communities, and some techniques include efficacy training, social role training, and vicarious learning.80 Physical addiction is seen as a symptom and is secondary in importance to the behavioral and psychological aspects of the individual’s drug abuse. Maintaining a drug-free lifestyle is the main goal of therapeutic communities, which also utilize a present-oriented approach that emphasizes personal responsibility as well as the development of positive values such as honesty, good work ethic, and community involvement.80 Although each individual is responsible for their own recovery process, the role each person plays in the recovery of others is also emphasized. Some of the daily activities of therapeutic communities include work, group sessions, and recreation. Individuals in the group serve as mediators and role models. They also confront misbehavior, rule violations, and share with one another during group sessions. Attitude and behavior change in relationships developed in the therapeutic communities serve an important function by helping maintain recovery after the individual leaves treatment.80

Condelli and Hubbard15 provide a comprehensive chapter that discusses client outcomes for therapeutic communities from admission to posttreatment. These outcomes were not derived from scientifically controlled studies using rigorous randomized control methods. However, they do reflect what happens to clients admitted to therapeutic communities in community settings. This chapter examines outcomes from a large-scale series of studies derived from the Drug Abuse Reporting Program. Clients in these studies showed a decline in drug use, including opioid use as well as nonopioid use, and also showed a decrease in arrest and incarceration rates. One of the most important and consistent predictors of the success of individuals was the amount of time they spent in therapeutic communities, although the length of time necessary to see positive outcomes varied from study to study. In a Drug Abuse Reporting Program follow-up study, therapeutic communities showed more favorable outcomes than outpatient detoxification and intake-only; they did not differ significantly from methadone maintenance or outpatient drug-free counseling.78

Therapeutic Communities

Therapeutic communities (TCs) are traditionally residential facilities in which the community structure and function are agents of change, and 12-step–based self-help programs guide individual recovery. Average lengths of stay are about 12 months (6-24 months). Community members progress through varying roles and responsibilities in their recovery and collectively ensure day-to-day functioning of the community. Days are highly structured and involve group and individual sessions, as well as time for community and personal chores and self-development, such as exercise, vocational time, and educational time. TCs have been successfully adapted to serve special needs populations, such as adolescents, patients with concomitant mental health disorders, patients with HIV infection, and women with children. Successful completion of a TC program has been shown to lead to a significant decrease in SUD behaviors. Day treatment or nonresidential TCs are also available and may be more cost-effective for patients with less severe social problems to address (NIDA, 2002).

Changing Therapeutic Community Practices

As federal and state substance abuse agencies were created in 1969 in response to President Nixon’s War on Drugs, the influence of new regulatory demands and the increased demand for practices that closely resembled hospital and medical clinics markedly changed therapeutic community practices.

Basic to the therapeutic community was the concept of clients and staff belonging to a single community in which therapy was an ongoing process, interactive dialogues were a primary aspect of community life, and counselors were fully engaged in this process, regardless of the time it took. Imposition of a strict 40-hour work week in which at least 10 hours was needed for paperwork (case notes, group notes, counseling notes, treatment plans, and revisions) played havoc with this concept.

Regulation and credentialization raised therapeutic community costs. The early therapeutic communities, built upon adult care paradigms, utilized a client (resident) workforce to perform all the many tasks necessary to maintain the community—food services, cleaning and repairs, auto maintenance, escort service, and administrative chores. Residents, as they rose in the hierarchy, also undertook supervisory functions. Moreover, the early therapeutic community was also predicated on a long-term care model, which gave the population a substantial group of more mature members who were actualizing recovery skills in their daily lives. Regulations now barred residents from certain tasks. Because counselors now spent substantially less time with clients and there were fewer senior residents (the elders of the early years) to serve as role models and monitors, staff needs increased. Whereas once a ratio of one counselor for 20 or even 30 residents was sufficient, regulations now called for ratios closer to 1:15.

Funding sources responded to increased costs with demands for shorter lengths of stay, and therapeutic community programs attempted to control expenditures by creating economies of scale, developing treatment settings capable of housing a client population in excess of—often far in excess of—150 residents. Although these settings were often able to reduce fixed costs for food and building supplies, they created issues of clinical management that also limited the time and quality of client interactions. One must consider Bill White’s admonition regarding threats to viability: “The twin threats of professionalism (preoccupation with power or status) and commercialism (preoccupation with money or property) have often proved fatal to advocacy movements.”69

The nature of therapeutic community treatment also reflected a changing treatment population. This was due, in part, to the criminal justice system’s widespread acceptance of treatment as an alternative to incarceration for most nonviolent drug law offenders. The courts, probation, and parole authorities became, for most therapeutic community programs in the United States, a major if not the sole source of referrals.

Glossary

Community therapeutic care program (CTC)

This program is a new approach to managing malnutrition at the community level. A CTC program has the same initial metabolic stabilization phase as a traditional feeding program, and life-threatening infections are identified and treated in the same way. However, once the patient is stabilized they move directly to an outpatient therapeutic program that operates through existing health structures and initiates nutritional rehabilitation with ready to use therapeutic foods (RUTFs). When there is no longer a risk of severe malnutrition, they are referred to supplementary feeding programs for recuperation.

These are persons fleeing from war, civil disturbance, and violence of any kind but who do not cross international boundaries.

These foods are ready to eat, and high in energy and protein. They also contain micronutrients and electrolytes. Their main use is for treatment of malnutrition. Their use to prevent stunting and wasting is also being evaluated.

This program deals with provision of high-quality foods to be consumed in addition to the usual diet, with either targeted (to prevent persons with moderate acute malnutrition from becoming severely malnourished) or blanketed (to prevent nutritional deterioration of a larger population) distribution.

Therapeutic Communities

Therapeutic communities for substance use disorders are based both in the community and in prisons and include a variety of short- and long-term residential and ambulatory programs that provide medical, mental health, vocational, educational, family counseling, legal, and administrative services.34 The general goal of therapeutic communities is to promote abstinence, change antisocial behaviors, and develop prosocial attitudes and skills by living together with others in a structured environment.172 Features that differentiate therapeutic communities from other residential treatments are their coordination of a comprehensive range of treatment services in one setting, use of the community itself as the therapist and teacher, and a view that holds that theindividual, not the drug, is the essence of the disorder.34 Another element of therapeutic communities is the encounter, a variety of peer-led supportive/confrontational sessions aimed at giving members feedback from others on whether they are meeting community expectations of recovery.34

A recent meta-analysis examining the efficacy of therapeutic communities showed that there is little evidence that therapeutic communities offer significant benefits compared with other residential treatments, or that one type of therapeutic community is better than another.149 However, the authors also acknowledged that the analysis may be biased and that firm conclusions cannot be drawn.

Therapeutic communities have been utilized frequently in correctional facilities.169 One meta-analysis demonstrated that prisoners with substance use disorders treated in therapeutic community programs have lower recidivism rates compared with those without treatment.124 Another study examined prison-based psychosocial treatments and reached a similar conclusion.103 Optimal results were seen when inmates participated in prison-based therapeutic communities that were followed by community-based aftercare.61,93

Therapeutic communities

The term ‘therapeutic community’ (TC) is generally used in the UK to describe small, cohesive communities where patients (sometimes referred to as ‘residents’) have a significant involvement in decision-making and the practicalities of running the unit. Key principles include collective responsibility, citizenship and empowerment, and TCs are structured in a way that deliberately encourages personal responsibility and discourages unhelpful dependency on professionals.

Patients are seen as bringing strengths and creative energy into the therapeutic setting, and the peer group is seen as all-important in the establishment of a strong therapeutic alliance. The belief in flattening of hierarchies and delegated decision-making may be seen by outsiders as facilitating something anarchic, but in reality there is a deep awareness of the need for strong leadership and a safe therapeutic frame (Campling 2001).

The power of groups was demonstrated in the UK in the Second World War by the Northfield experiments, named after the Northfield Hospital in Birmingham. Here, an army psychiatric unit was run along group lines, and some prominent figures, including Bion, Foulkes and Main, were involved. Bion went on to write about groups and became a prominent Kleinian theoretician (see above). Foulkes is one of the founding fathers of group analysis, and Main described the therapeutic community, an institution where ‘the setting itself is designed to restore morale and promote the psychological treatment of mental and emotional disturbance’. Main went on to create the influential example of the Cassel Hospital in Surrey.

Maxwell Jones founded the Belmont in the 1950s, later called the Henderson Hospital, in Sutton, Surrey. Here, the community was the main focus, and careful procedures for admission, discipline and discharge were established over many years. The hospital treated patients with severe personality disorders, with a regime characterized by what the anthropologist Rapoport (1960) termed ‘permissiveness, reality-confrontation, democracy and communalism’.

Permissiveness encourages the expression and enactment of disturbed feelings and relationships, so that they can be examined by patients and staff alike. Differences between patients and staff are minimized, and decisions are made with residents having a majority vote (and often being harsher than staff members themselves). Permissiveness is usually limited to the verbal expression of feelings, and would be strongly confronted if it led to other members of the TC being emotionally hurt or damaged, or feeling marginalized or excluded. Racist comments, for example, would not go unchallenged in modern TCs (Campling 2001).

A further important observation form Rapport's study was the repeated cycle of oscillations: times of healthy functioning, when residents were well able to manage responsibility and a level of therapeutic permissiveness; and other times when high levels of disturbed behaviour have meant that staff had to take a more active role. A further observation was the conflict between those whose main objective was preparing residents for the outside world, and those whose main objective was helping residents to better understand their inner worlds – a tension between ‘rehabilitation’ and ‘psychotherapy’ that still persists in many modern TCs. The Henderson was in many ways the prototypical therapeutic community.

Clark (1977) has described three important terms:

Therapeutic community or therapeutic community proper refers to the specific type of therapeutic milieu set up by Maxwell Jones and followers, e.g. Henderson, ‘a small face-to-face residential community using social analysis as its main tool’

Therapeutic milieu is a social setting designed to produce a beneficial effect on those being helped in it, e.g. a sheltered workshop, hospital ward, hostel

Social therapy is the least specific term, employing the idea that the milieu or social environment can be used as a mode of treatment.

TCs have a long history of involvement in research. Much of this has been from a social science perspective and qualitative in nature. Some of it is of importance to other areas of psychiatry, for example methodological approaches to develop, describe and measure the therapeutic milieu, of which the Ward Atmosphere Scale developed by Moos is the best example. Over the past decade, researchers based at both the Henderson and the Cassel hospitals have produced methodologically sound research demonstrating the cost-effectiveness of their treatments (Norton 1996).

TCs are seen to have a valuable role to play within the future of mental health services. Within the NHS in the UK, they have established a niche for those suffering from severe emotionally unstable personality disorder, a group of high risk patients who become heavy users of services if they do not receive the intensive long term psychosocial therapy they require.

The application of TC ideas, like ideas from psychodynamic, systemic and group therapy, has had an important impact on the general practice of psychiatry.

Therapeutic Communities

Early programs established in the United States in the 1950s were labeled therapeutic communities. Established as long-term treatment centers, the basic premise for treatment was relearning of skills necessary for a drug-free life. Residents were expected to acquire new skills for living, earning privileges as they took on more responsibilities. Their daily schedules included chores, classes designed to help them resume formal education, and verbal groups. One early program, Synanon, however, gained a great deal of notoriety for becoming a cult and exercising strict control over the residents. Current treatment programs are now based upon specific treatment models that are not limited to behavior management, but also include reality therapy, psychodynamic approaches, and social/cognitive frames of reference.

Currently there are over 500 substance abuse and mental health treatment programs that provide a variety of services for persons with substance abuse disorders. Services include assessment, detoxification, residential treatment, transitional housing and treatment, educational and vocational services, and continuing care. In a 2003 survey of therapeutic communities, there were over 19,000 beds and almost 11,000 slots reported to be available for outpatient treatment. This translated into a total of 55,910 individuals treated residentially, and 28,245 treated on an outpatient basis in the year 2002. This study did not account for the beds and outpatient slots that are part of general hospitals.18

Wandering and Elopement

Some residents in long-term care facilities, in addition to presenting risk associated with resident on resident or resident on staff violence, may indeed be at risk themselves as a result of wandering away from the facility where they receive care.

The tragic case of Joan Warren in North Vancouver, Canada in 2013 is unfortunately only representative of the many similar cases experienced in the long-term care sector around the world. A 76-year-old woman suffering from dementia wandered away from her seniors home and, after an exhaustive ground search, was found dead of hypothermia a couple of days later, just off a trail in a park. The case, and another that followed in the Vancouver area some months later, prompted questions about security and the possible use of technology to mitigate the risk associated with the wandering behaviors.20

Individuals at risk of wandering include those with dementia, “generally in the early to mid-stage” according to the National Council of Certified Dementia Practitioners (NCCDP). While reminding us that dementia is not a disease in itself, but rather a group of symptoms associated with Alzheimer’s disease, the NCCDP suggests that more than 34,000 U.S. Alzheimer patients wander out of their homes or care homes each year.1

For the long-term care homes, the challenge is maintaining a warm and therapeutic home environment for their residents, while at the same time, mitigating the risk of wandering presenting by an increasing number of residents. Some of the design challenges can be seen as similar to those experienced in designing for elopement prevention in behavioral/mental health. There has been a move toward designing secure dementia units or even facilities designed specifically for dementia patients. Some of the key design features in attempting to mitigate the risk of elopement in long-term care include:

Building Perimeter – capacity to detect exit and provide camera images of resident

External Areas – securable outside areas where residents can frequent

External Response – presence of a plan to facilitate quick recovery of resident

Main Entry/Foyer – observational capacity of most vulnerable area in any facility

Internal Controls in the Building – stairwells, elevators, circulation routes, exit doors

Unit Design – line of sight for staff, unit entry, patient wandering system

Other – testing of system components, community awareness.

Electronic resident wandering systems are used in many facilities to assist with early detection of residents with a propensity to wander. In simple terms this consists of a transmitter, usually affixed to a bracelet on the resident’s wrist. Receivers are situated at key locations in the facility so that if the resident wearing the bracelet passes close to the receiver an alarm sounds and staff can respond. While these devices have, to some degree, helped mitigate the risk of wandering, they are dependent on staff diligence and response. Residents can remove them and, not unlike infant tagging systems, alarms generated by these systems can be lost in the noises of a busy unit and, especially if subject to false alarms, can be viewed as a nuisance by staff over time.

For security, in these circumstances the task becomes to ensure a good design to mitigate the risk of wandering, to support staff training in the use of the system and to provide a rapid and thorough response to any report of resident elopement, where such responsibility exists. As an example, a good external camera system, quickly available to security for review, can help determine whether a search should be externally or internally focused, increasing the likelihood of a positive outcome.

Circumstances, Motivation, Readiness and Suitability scales (CMRS)

The 25-item CMRS, which was originally developed for use with adults in a therapeutic community setting, has also been evaluated for use with drug-abusing adolescents (Jainchill, Bhattacharya & Yagelka, 1995). The questionnaire consists of four scales and a total score designed to predict retention of treatment. The scales include Circumstances (external motivation), Motivation (internal motivation), Readiness (for treatment) and Suitability (perceived appropriateness of the treatment modality). The scales have favorable internal consistency (alpha’s ranging from .77 to .80), and they moderately predict short-term (30-day) retention.

Therapeutic communities (TCs) in prisons and jails

With the creation of the Residential Substance Abuse Treatment (RSAT) initiative in 1994, modified Therapeutic Communities (TC) within prisons were promoted as a novel form of substance-dependence therapy in correctional settings. In Therapeutic Communities, inmates are housed separately from the general population, and participate in several months of intensive rehabilitation, self-help and peer groups, drug-abuse education classes and professional counseling. Therapeutic Communities are the most common substance-use program that is offered for more than 90 days (Taxman et al., 2007). There is some evidence, both nationally and internationally, to suggest that Therapeutic Communities are associated with reductions in post-release drug use and recidivism (Lipton, 1995; Pearson and Lipton, 1999). However, the effectiveness of these programs has recently been questioned. A report by the California Office of the Inspector General reported that US$1 billion had been spent on treatment programs for incarcerated persons, without evidence of effectiveness (Cate, 2007). It should also be noted that there is little evidence showing that Therapeutic Communities are significantly better than other types of residential treatment (Smith et al., 2006). In addition, one of the primary challenges with providing more intensive treatment services to substance-dependent inmates is that these services may counteract the retributive and incapacitating nature of correctional facilities (Taxman et al., 2007).