A Therapeutic Approach to Substance-Use Disorder

By Jiacheng Ren

This is the second analysis in the “Epidemic in a Pandemic” series that looks at what has happened to substance-use treatment access and effectiveness during COVID-19. Read the first analysis here.

If opioid-use disorder is a problem, how do we address it? At the most basic level, people need care for their addictions. But there is not one standard way to address opioid-use disorder. In the second part of our series on treatment, we look at the therapeutic approach, which does not rely on medication as the primary intervention.

Introduction

Opioid-use disorder is a complex disease with pervasive consequences. As such, treatment interventions involve a variety of approaches delivered in many different settings. In addition to medication-assisted treatment (MAT), which has received significant attention, there are other treatment options, such as the 12-step program and the therapeutic community, which do not view and use medication as the primary therapeutic intervention.

The legacies of the US government’s response to drug dependencies in the early 20th Century contributed to the development of 12-step programs and therapeutic communities, and hence, have long influenced current treatment modalities. The first major national narcotics law in the US, the Harrison Narcotics Act, was passed in 1914 as a response to the prevalent opiate, especially morphine, addiction caused by doctors’ overprescribing of the drugs for profit. The 1914 law, aimed at controlling the distribution of narcotics, subsequently turned into a de facto ban on the prescribing of narcotics to treat narcotic addictions. Government agencies investigated doctors using opiates to treat drug addictions and closed morphine dispensaries in communities.[1] Arrest and incarceration, instead, became the standard interventions for drug addictions. To alleviate the burden on the federal prison system, the US government constructed the first two federal prison-hospitals for incarcerated persons and voluntary patients with drug addictions in the 1930s.

…the current opioid crisis demands an encompassing model of care.

The message underlying the government’s approach was that drug addiction was not a disease but a crime and that drug users were moral derelicts who needed retribution and rehabilitation.[2] Consequently, in the early 20th Century, there were very few treatment services available for drug addiction. Abstinence-based self-help recovery organizations, such as Alcoholics Anonymous, emerged as alternative recovery resources in the 1930s.

The Self-Help Recovery Movement

Alcoholics Anonymous was co-founded in 1935 by two people in recovery who believed that sobriety could be achieved and maintained when struggling addicts share their stories with one another. The founders of Alcoholics Anonymous adapted the blueprint of self-improvement from a Christian organization, the Oxford Group, incorporating moral and spiritual elements into recovery.[3] The 12-step recovery program established by Alcoholics Anonymous requires members to acknowledge they are powerless over addiction, surrender to a higher power to seek help in changing themselves, examine their self, confess and make amends to others, pray in the personal struggle, and help others suffering from the same addiction. The overarching belief of Alcoholics Anonymous is that psychic awakenings lead to behavioral changes. In essence, this program encourages members to both look outside themselves for the ultimate spiritual source of recovery and take active responsibility for personal changes by committing and adhering to the principles and activities of the 12 steps. While focusing specifically on recovery from alcohol dependence, Alcoholics Anonymous acknowledges that many people who suffer from alcoholism also have dependencies on drugs.

To better support people with drug dependence (other than alcohol) as the primary concern, groups adopted the 12-step program. Narcotics Anonymous was officially established in 1953. Most of its founding members had participated in Alcoholics Anonymous. Following the growth of Narcotics Anonymous, more drug-related 12-step groups were created, such as Cocaine Anonymous and Heroin Anonymous. Despite their different names, these groups promote complete abstinence from all mind-altering drugs and alcohol. In keeping with the 12-step tradition, they hold regular assemblies of 12-step meetings for anyone expressing the desire to break free from addiction. Memberships are generally informal, anonymous, and free. Recovery is considered a lifelong endeavor. The vast majority of the fellowships are true self-supporting and mutual aiding without any leaders or administrators, as well as clinicians or therapists.

Therapeutic Communities

Long-term residential facilities for people addicted to drugs, based on the self-help principles of Alcoholics Anonymous, also emerged in the late 1950s. The prototype of therapeutic communities for addiction, Synanon, arose in 1958.[4] Synanon’s founders integrated their experiences as members of Alcoholics Anonymous with treatment concepts from the psychiatric therapeutic community in military medicine.[5] Within a year, Synanon expanded to a peer-driven residential community. At Synanon, recovering individuals lived together, maintained the property together, and followed a strict household structure. Its “no nonsense” approach included controversial tactics, such as the use of confrontational interventions to ensure members were truly committed to treatment. The Brooklyn probation department founded the second addiction therapeutic community, Daytop Village, in 1963. Throughout the mid-1960s and 1970s, former members of Synanon and Daytop Village implemented therapeutic communities throughout the US.[6] Although Synanon itself was eventually closed due to criminal activity and scandal, the therapeutic community model achieved a predominant position in the addiction treatment field in the mid-1980s. Basic elements of the original programs, such as the philosophy, social organization, and practices, are still followed by many current therapeutic communities.

While the primary goal of the 12-step program is to maintain abstinence, therapeutic communities place a greater emphasis on personality and lifestyle changes.

The therapeutic community model shares the principles of mutual self-help and self-examination, as well as the practice of regular group meetings with the 12-step program. Nevertheless, it evolved as a distinct treatment and recovery program. While the primary goal of the 12-step program is to maintain abstinence, therapeutic communities place a greater emphasis on personality and lifestyle changes. The goal is to treat not just substance use but also underlying reasons contributing to it, including deeper psychological and socialization problems. Recovery involves rehabilitation—modifying dysfunctional behaviors and thoughts and developing skills of functional and healthy living.

To achieve such complex goals, therapeutic communities use the peer community as the agent of recovery—their defining treatment approach.[7] Change occurs when recovering individuals participate as functional community members in an intensive 24-hour residential community under a highly-regulated daily regimen. In contrast to the 12-step program’s reliance on an external power, therapeutic communities place a greater emphasis on the self and group process as the source of recovery. Varied situations of community life and continuous social interactions facilitate social learning and foster new pro-social attitudes and behaviors. A structured daily routine helps members to live an ordered and productive life. Group therapies, as well as individual counseling, encourage members to identify and discuss their behaviors and feelings and to learn the positive ways of managing them. Work therapies, by comparison, teach members responsibility, accountability, and self-reliance. And finally, vocational and educational training prepare members for a fulfilling life after they leave the therapeutic community.

Unlike the relatively unstructured 12-step fellowship, therapeutic communities have a hierarchical model of care. Traditionally, there are three main program stages: assimilating into the community, receiving primary treatments, and re-entering the outside society. Community members are also stratified into levels defined by their community status or seniority. The sequential stages and levels of membership are associated with greater privileges and reflect increased levels of personal and community responsibilities. Members can transition to higher levels or program stages when they meet the program’s specific expectations for progress. The therapeutic community philosophy holds that members are responsible for and dependent on each other. Therefore, members with higher levels serve to help those in earlier stages of recovery; and members learn to understand how individual actions can affect the whole community through behavioral modification or disciplinary sanctions. In this sense, therapeutic communities exhibit elements of both self-help and authoritative leadership.

The traditional therapeutic community, from its root, reflects psychological rehabilitation concepts grounded in the criminal view of drug addiction, which was prevalent in the first half of the 20th century.[8] The function of therapeutic communities is to give recovering individuals with core social deficiencies a second chance to develop interpersonal and emotional competencies. As such, therapeutic interventions have been criticized as confrontational and dehumanizing at times. Research studies have shown the therapeutic community is an effective approach for treating substance dependencies. However, there is insufficient evidence that the therapeutic community is more effective than other residential treatments.[9] The evidence base for the effectiveness of therapeutic communities is also limited due to the lack of randomized controlled trials and therapeutic communities’ incorporation of other evidence-informed treatments evolving outside therapeutic communities. Similarly, the effectiveness of the 12-step program has also garnered controversy and the research evidence is mixed.

Developments in Treatment Approaches

The traditional 12-step fellowships like Alcoholics Anonymous and Narcotics Anonymous are based upon total abstinence from all mind-altering substances. As a result, modified 12-step fellowships, such as Dual Recovery Anonymous and Double Trouble in Recovery (DTR), have developed to offer recovery support to individuals with dual-recovery needs for substance use dependences and mental illnesses. Similarly, Methadone Anonymous[10] and the more recent Medication-Assisted Recovery Anonymous (MARA) have emerged for individuals on opioid agonist maintenance who also wish to benefit from 12-step participation. Additionally, for individuals who are not comfortable with the idea of surrender or the religious element of 12-step programs, there are alternative peer-sharing groups like Self-Management and Recovery Training and Moderation Management.

Therapeutic communities have also become more sophisticated, providing a full continuum of care and broader treatment options.

Beyond fellowships, the 12-step program has been promoted, modified, and incorporated in other treatment services, including residential programs, intensive outpatient programs, and aftercare services. Many of these programs use both the 12-step methodology and research-based therapeutic strategies, providing a more comprehensive service of care. For example, Hazelden, a leading treatment institution that was historically based on the 12-step program, has integrated the 12 steps, MATs, and other successful treatment strategies into their practice. According to SAMHSA, in 2018, the 12-step facilitation therapy was used by approximately 72 percent of treatment centers and 67 percent of methadone clinics in the US.

The therapeutic community has also adapted to changes in our understanding of addiction, including changes in treatment needs, client population, social attitudes, health care landscape, and scientific research. First, therapeutic communities have become more professionalized.[11] While therapeutic communities were historically staffed mostly by recovered peers, there has been an inclusion of increasing proportions of professional staff with substance use counseling or mental health training. An emphasis on charismatic leaders has been replaced by peer leadership, multiple decision-makers, and role-model staffs. The financial support of therapeutic communities has shifted from private sources to public funding, which makes therapeutic communities subject to accountability and external monitoring. Following the advances in practice, the duration of residential stay has changed from indefinite to a planned treatment duration according to the treatment plan and protocol. In recent years, long-term residential therapy has shortened from 24 months to 3 to 12 months due to health care costs and limited government budgets, though some longer programs still exist.[12]

To meet the special treatment needs of different populations, modified therapeutic communities beginning in the 1990s started to serve various subgroups of recovering individuals. For example, Dynamic Youth Community is a specialized program for adolescents and young adults. Other treatment centers offer a range of unique programs for individuals of all ages (e.g., Odyssey House), as well as for women with children (e.g., Odyssey House, Phoenix House, Samaritan Daytop Village), veterans (e.g., Phoenix House, Samaritan Daytop Village), people with co-occurring psychiatric disorders (e.g., Odyssey House, Phoenix House, Samaritan Daytop Village), and so on. In modified therapeutic communities, the treatment practices are tailored according to issues and problems specific to the subgroup. In Dynamic Youth Community, for instance, the treatment approach is less confrontational, with a focus on the developmental issues that young people face.

Therapeutic communities have also become more sophisticated, providing a full continuum of care and broader treatment options. Although therapeutic communities are traditionally in residential settings, they have also developed outpatient programs (intensive, regular, and day program), ambulatory treatment centers, and aftercare programs. Residential programs have been divided into short-term (one to three months) and long-term (six months and longer). In doing so, recovering individuals, with the help of clinic staff, can choose a program that best fits their personal situation and the necessary time they need in treatment. Continuing care post-treatment also helps individuals to reinforce their recovery results while re-adjusting to normal life routines. Some treatment centers, such as Samaritan Daytop Village and Odyssey House, provide supportive housing for people who are engaging in or have completed treatment programs.

Initially, therapeutic communities forbade the use of medications of any kind, as communities viewed themselves as an alternative to medically-oriented treatments. However, in responding to changes in culture, treatment practice, and research, many therapeutic communities have adopted an integrated model of care—a combination of behavioral therapies, 12-step programs, comprehensive medical treatments, and other forms of treatment. Many therapeutic communities also now accept recovering individuals on psychiatric medications and on medication-assisted treatment, or incorporate these medications into their own treatment services. For instance, Odyssey House, Phoenix house, and Camelot provide naltrexone, buprenorphine, or Suboxone. And Samaritan Daytop Village offers methadone in addition to naltrexone and buprenorphine. At the same time, the earlier punitive dimensions of therapeutic communities have softened.[13]

Overall, it is fair to say that treatment modalities like therapeutic communities and 12-step programs have developed from alternative self-help groups for so-called deviants to mainstream human service agencies for patients struggling with substance dependence.[14] While many 12-step programs and therapeutic communities do not accept MAT, or only accept it for stabilizing patients after detoxification, the recent shift towards incorporating medical treatments in certain organizations might suggest that abstinence-based therapeutic interventions and MAT do not have to be at odds. Rather, the current opioid crisis demands an encompassing model of care.

Behavioral therapies are used in medication-assisted treatment and other non-medical treatment models. Examples of evidence-based behavioral therapies to treat drug use disorder include substance use counseling, community reinforcement, contingency management, motivational interviewing, cognitive-behavioral therapy. relapse prevention, brief intervention, family therapy, and so on. For more information on behavioral therapy, please see Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).

 

ABOUT THE AUTHOR

Jiacheng Ren is a research assistant at Rockefeller Institute on the Stories from Sullivan project and a Ph.D. candidate at the Department of Political Science, Rockefeller College of Public Affairs and Policy, University at Albany

[1] David F. Musto, The American Disease: Origins of Narcotic Control (Oxford University Press, 1999).

[2] Dean R. Gerstein and Henrick J. Harwood, “Treating drug problems. Volume 1: a study of the evolution, effectiveness and financing of public and private drug treatment options,” (1990), https://www.ncbi.nlm.nih.gov/pubmed/25144071.

[3] Ernest Kurtz, Not God: A History of Alcoholics Anonymous (Simon and Schuster, 2010).

[4] Frederick B. Glaser, “Some historical aspects of the drug-free therapeutic community,” The American journal of drug and alcohol abuse 1, no. 1 (1974): 37-52, https://www.tandfonline.com/doi/abs/10.3109/00952997409031906.

[5] Maxwell Jones, The Therapeutic Community: A New Treatment Method in Psychiatry (New York: Basic Books, 1953).

[6] George De Leon, The Therapeutic Community: Theory, Model, and Method (Springer, 2000).

[7] De Leon, The Therapeutic Community: Theory, Model, and Method.

[8] Gerstein and Harwood, “Treating drug problems,” https://www.ncbi.nlm.nih.gov/pubmed/25144071.

[9] Lesley A. Smith, Simon Gates, and David Foxcroft, “Therapeutic communities for substance related disorder,” Cochrane Database of Systematic Reviews 1 (2006), https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005338.pub2/abstract.

[10] Stephen M. Gilman, Marc Galanter, and Helen Dermatis, “Methadone Anonymous: A 12-step program for methadone maintained heroin addicts,” Substance Abuse 22, no. 4 (2001): 247-256, https://www.ncbi.nlm.nih.gov/pubmed/12466684.

[11] De Leon, The Therapeutic Community: Theory, Model, and Method.

[12] George De Leon and Harry Wexler, “The therapeutic community for addictions: An evolving knowledge base,” Journal of Drug Issues 39, no. 1 (2009): 167-177, https://journals.sagepub.com/doi/abs/10.1177/002204260903900113.

[13] Gerstein and Harwood, “Treating drug problems,” https://www.ncbi.nlm.nih.gov/pubmed/25144071.

[14] De Leon, The Therapeutic Community: Theory, Model, and Method.


READ THE SERIES

In “Epidemic in a Pandemic” the Rockefeller Institute’s Stories from Sullivan team examines what has happened to substance-use treatment access and effectiveness during COVID-19. Follow along here and on social media with the hashtag #StoriesfromSullivan.

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