Bridging the Gap Between Research and Practice in Therapeutic Communities (TCs) for Addictions

Therapeutic communities (TCs) are well-known as a treatment modality and can be found in a variety of populations and settings, including addicts, as well as children and young people, individuals with personality disorders and learning disabilities, prisons and hospitals (see Boyling, 2009; De Leon, 2000; Kennard, 1998; Vanderplasschen, Vandevelde, & Broekaert, 2014). The term therapeutic community was first used by the British psychiatrist Tom Main (1946), who was involved in the so-called Northfield Experiments (see Vanderplasschen, Vandevelde, De Ruysscher, Vandevelde, & Broekaert, 2017), where soldiers suffering from shell shock and war neuroses after the Second World War were treated by using group processes therapeutically (Harrison & Clarck, 1992). From that time forwards, the term therapeutic community has been linked to a range of treatment traditions and approaches that essentially share the “idea of using all the relationships and activities of a residential psychiatric centre to aid the therapeutic task” (Bridger, 1985, p. 60). One of these traditions is commonly referred to as drug-free or hierarchical TCs, also called concept(-based) TCs or TCs for addictions (Vanderplasschen et al., 2014). These TCs were developed in the 1960s as intensive inpatient-type programs to get people off drugs and to provide a complete break from their past lifestyle. Numerous residential programs for addicts have been modelled after this original concept and also drug-free TCs themselves have evolved and been modified to address the needs of specific groups, such as adolescents, mothers with young children, incarcerated substance abusers, or persons with co-occurring mental disorders. Community as method has been identified as the core and common mechanism across TCs (De Leon, 1997). It has been described as “teaching individuals to use the context of community life to learn about themselves” (De Leon, 2000, p. 93) and refers to peer and staff relationships, social roles, the social structure, group process and daily activities.

Two years ago we agreed to prepare a special issue of the Journal of Groups in Addiction and Recovery (JGAR) on TCs. This decision was inspired by a series of informal discussions during the 15th conference of the European Federation of Therapeutic Communities, which was held in Prague in September 2013. It is not unusual in real life, nor in our work to take impulsive decisions based on frustrations and this was precisely the case here. We witnessed a wide range of high-quality presentations and workshops on research in TCs but were saddened to realize that few if any of these studies were likely to find their way into the pages of peer-reviewed academic journals. Our frustrations at that time centered on the apparent continuing void between the research and practitioner communities; with researchers bemoaning the failure of drug treatment agencies to modify practices in line with research findings and practitioners arguing that the research community was failing to undertake studies in areas which they would find helpful and producing results that were inaccessible and impractical. Moreover, although the conference vividly illustrated both the exciting and creative interventions being undertaken within TCs and an openness to improve practice, there was a continuing dearth of research published outwith the immediate field. Despite the fact that TCs represent one of the most widespread and successful approaches to addiction treatment and recovery, the number of studies and research activities in TCs is relatively limited and has not led to the scientific output that may have been expected based on this rich tradition.

Clinical research in TCs is relatively new and limited and is still a blank spot on the world map of addiction research, despite some research projects and interesting publications that have predominantly been published as research monographs. Moreover, a language barrier causes the loss of many interesting papers and valuable experiences, as they are not published in widely available English-language scientific journals. A special language working group has been started under the umbrella of the International Society of Addiction Journal Editors, of which JGAR is a long-term member, where journal editors discuss how to support important activities and research areas and to effectively bridge the gap between clinical practice and the research world. This special issue of JGAR can be regarded as a partial answer to this challenge, because our aim was to invite research teams from various countries to present diverse research projects targeted at different clinical phenomena. Methodological pluralism and a variety of research traditions are exactly what we wanted to present in this special issue to show how many “colors” can be recognized in this field. These are considered excellent opportunities for future clinical research and may add new scientific perspectives.

TCs represent a very attractive setting for clinical research from different perspectives, including the study of new phenomena, research on treatment process and effectiveness, and the implementation of innovative methods in a relatively homogenous context. The effectiveness of TCs for addictions has been studied extensively, but conclusions from available research are not unequivocal. TCs are often criticized for the high drop-out and relapse rates and considerable costs of treatment, despite substantial benefits observed among those who complete and/or stay long enough in treatment (De Leon, 2010; Vanderplasschen et al., 2013). Several articles in this special issue address TC effectiveness and interventions/techniques to enhance retention, which is considered the primary predictor of successful outcomes.

Šefránek and Miovský report on TC outcomes among a large sample of methamphetamine users recruited in four traditional TCs in the Czech Republic. Few studies have focused on the effectiveness of (residential) treatment for the emerging methamphetamine problem. Findings indicate favorable substance use related outcomes 1 year after discharge, as well as satisfactory treatment completion rates.

Rome and colleagues describe a similar outcome study, based on a 12-month follow-up among participants of a 12-week modified TC program in Edinburgh, Scotland. The modified TC is an abstinence-oriented, quasi-residential rehabilitation service that uses the community as an agent of change as well as various prototypical TC elements. Results confirm earlier findings regarding the effectiveness of (modified) TCs for improving substance use and risk behavior up to 1 year after treatment, in particular amongst those who completed treatment.

The longitudinal study by Goethals and colleagues focuses on the association between time in treatment and TC participants' perceptions of treatment process in four Belgian TCs for addictions. The article illustrates participants' growing connection with the TC process and identity change, which is linked to levels of psychopathology, psychological well-being, and pretreatment motivation.

Self-help and peer support are essential elements of the TC method (De Leon, 2000). The qualitative study by Turpin and Shier explores the various roles that peer support may have in addiction treatment, based on interviews with participants from long-term programs in the Toronto Area in Canada. Diverse functions of peer support are illustrated, which encourages the further integration of experts by experience in various types of (residential) addiction treatment facilities.

Two articles in this special issue focus on specific topics that may challenge TC effectiveness: the role of ADHD and impulsive choice/action on the treatment process and the importance of supported/supervised housing after initial treatment. Based on a study of ADHD and impulsivity in Czech TCs, Kalina and colleagues assess gender differences between residents with and without ADHD and its impact on the TC process and outcomes. Given the higher problem severity in women with ADHD, the authors stress the importance of the assessment of dimensions of impulsivity, attention and concentration at treatment entry for their impact on the treatment process.

Recovery residences have been described as environments supporting addiction recovery and modified versions have been developed to address the needs of specific populations like ethnic minorities. Garcia and colleagues compare the anexo, with its origins in Mexico and Alcoholics Anonymous, with other types of recovery residences in the United States. The anexos are regarded much needed recovery services for Latino communities, as they offer affordable and culturally sensitive support and serve some of the most marginalized and vulnerable populations suffering from addictions.

The four remaining articles address the recurring question of how TC environments can be maintained and/or adapted as effective and attractive growth and recovery promoting places. The article by Vanderplasschen and colleagues emphasizes the role of research in shaping TC environments into contemporary, client-centered, and effective treatment environments, while adhering to the community as method (De Leon, 2000). The authors present a case study of the history and development of TC De Kiem (Belgium) and scientific research on practice and innovations over the past 40 years that promoted its evolution.

In a critical analysis of integrated and multidisciplinary practices, Yates and colleagues challenge the assumption that integrated and multidisciplinary substance abuse treatment is necessarily good and efficacious, in particular in complex therapeutic environments like TCs. The article focuses on several areas of integrated working, like the integration of ex-addicts and other disciplines, implementation of new approaches and collaboration with organizations with different treatment philosophies.

Broekaert and colleagues address the topic of quality of life (QoL) and why it has been understudied in TCs that are usually evaluated using socially desirable outcomes like abstinence, employment, and desistance from criminal activities. In an attempt to understand this missing link, the background and focus of both approaches (TC and QoL) is compared, leading to the conclusion that although both movements are grounded in different philosophies they are complementary and can learn from each other.

Finally, Lin and colleagues present an adaptation of the TC method in a school environment in Hong Kong, a notorious region for the government's zero-tolerance drug policy. Based on a multimethod phenomenological approach, the Christian Zheng Sheng College is described as an integrated program offering education and drug abuse treatment and recovery services. Although clearly distinct from the traditional TC approach, a spiritual and holistic treatment model is presented which might be culturally sensitive.

Eventually, during the 2-year period of preparing this special issue, we lost two brilliant colleagues who were undertaking research on TCs and had contributed actively to this special issue. Two research teams that prepared manuscripts for this special issue lost a beloved friend and colleague in the autumn of 2016. The Department of Addictology at the Charles University in Prague (Czech Republic) was affected by the loss of Dr. Lenka Čablová, one of its key academics who made a very promising start to her professional career. Lenka was a successful researcher in the area of preventive and clinical research in addictions but died very young (at age 30) after a hard and long illness. Eric Broekaert, who was attached to the Department of Special Needs Education at Ghent University (Belgium), was one of the foremost advocates and leading researchers of the European TC movement who published numerous papers on TCs for addictions. Eric's interest in TCs began early in his academic career, when he started a drug-free TC (De Kiem). De Kiem recently celebrated 40 years of work in the addiction field and became a template for other TCs across the world. Eric Broekaert was also a central figure in the creation and development of the European Federation of Therapeutic Communities (EFTC). Moreover, he recognized early the need to develop the scientific foundations for the TC methodology and, therefore, would have been tremendously proud of the realization of this special issue. We dedicate this special issue to both of them and will miss them terribly.