What future for the Therapeutic Community in the field of addiction? A view from Europe

This is the authors' abstract. We don't add key points for this paper.

The drug-free, hierarchical, concept-based Therapeutic Community (TC) is one of the most widely recognized and documented treatment modalities for substance abusers. Many studies have reported on its method, functioning, results, history, ideology and background [1]. The TC promotes changes towards a drug-free life-style through living together in a structured way. The concept was developed at Synanon, in the beginning of the 1960s, and can be traced back to the Christian-inspired Oxford Group Movement, Alcoholics Anonymous, Eastern religions, American idealism, humanistic psychology and existentialism. Through Daytop and Phoenix House, both based in New York, it grew in popularity in the United States and Europe. In Europe it developed its own identity. It interacted with the milieu-orientated Maxwell Jones-type TC and was influenced by the critical left-wing ideologies of the 1960s and the anti-psychiatric movement. It personified a new Christian spirituality. American behaviour modification was tempered by a tradition of incorporating more dialogue. Confrontation during encounter groups was replaced by striving for more ‘understanding’ of human problems. Learning experiences, such as wearing signs, never caught on in Europe. On the other hand, the unique contribution of ex-addicts was taken over increasingly by professionals who introduced their own skills, such as gestalt therapy, transactional analysis, psychodrama, cognitive therapy, etc. [2]. In France there was open criticism against the ‘conforming’ American TC. This resistance held back the full development of the European TC for many years. Since the 1980s, many TCs in various European countries (Great Britain, the Netherlands and Sweden) have been closed down. It was difficult for the TCs to cope with the AIDS epidemic and to provide and adapt treatment for the constantly growing number of addicts. This demand was better fitted by harm reduction approaches and methadone programmes. Even more fundamentally, the European TCs' value system was criticized. This system is built upon the belief that everyone has the potential to develop, that the responsibility to change lies with the person themselves, that others can only assist by being role models, that honesty pays, that guilt-sharing blocks destructive processes and that a drug-free life-style prevails. The harm reduction model linked up with a new philosophy and proclaimed that harm being done to the person as well as to society has to be prevented, that total abstinence is not realistic, and that it is possible to use drugs in a controlled, risk-free way. The encounter groups were criticized for their attempt to indoctrinate the value system: by using the power of the group to change behaviour towards TC values this approach neglected the individual decision-making and the social rights of the residents. In the United States, the TC value system was less under attack, as it connected better with the prevailing, more conservative neo-liberal ideology and the temperance movement. At the same time, policy makers demanded managed care that insisted on evidence of effectiveness and efficiency. European TCs' cost was considered too high in relation to the benefits. This in contrast to the United States where, due to the less professional but more self-help nature of the programmes, the costs for professional staff were lower and the gains in reducing crime higher. The European TC, however, unlike the American TC, had a limited culture of research and had difficulty in finding evidence for its functioning. It relied mainly upon American studies until, within the network of the European Working group on Drugs Oriented Research, a research tradition was begun in close collaboration with the European Federation of Therapeutic Communities. TC research showed that ‘time in treatment’ could be viewed as the most powerful predictor of a successful outcome of TC treatment [3,4]. Given that the dropout phase is at its highest during the first 2 months of treatment, the TCs decided to introduce various methodologies to boost retention [5]. TCs encouraged the use of ‘senior staff’[6] as well as family and social network support [7]. The value of these findings was supported by uncontrolled large-scale comparisons and multi-site field effectiveness studies conducted in Great Britain [National Treatment Outcome Research Study (NTORS)] and the United States [Drug Abuse Treatment Outcome Study (DATOS)][8]. The European TC accepted that both residential and methadone treatments are effective [9]. They saw, in comparison to other residential approaches, the effectiveness of their treatment first and foremost as a collection of good practices that enhance the quality of life. This incontrast with the findings of some meta-analyses [10] that, from a TC point of view, suffer from statistical problems [11], and with only a very limited number of the TC studies meeting all methodological criteria [12]. The drug-free TC extended its approach to other target groups, such as prisoners, mothers and children, adolescents, dually diagnosed residents, methadone-maintained clients, chronic abusers and mental health patients [13]. TC treatment, methadone programmes and harm reduction methods have been integrated [14]. Brief interventions have been introduced that utilize family and social network support. The TC movement has adopted post-modern approaches that advocate the introduction of shorter programmes, de-institutionalization, outreach and community-based interventions. It learned its lesson from earlier experiences of charismatic leadership. Clearly, a rigid value system becomes a weakness if it leads towards therapeutic fundamentalism. On the other hand, psychiatric hospitals have begun to use typical TC tools, such as the structuring of day-to-day life in combination with a confrontation of behaviour during group therapy. During the last few years the TC movement has expanded into Eastern Europe and the former Soviet Republic. Even in France it will now be given a chance, as the interministerial commission against drugs and addiction intends to open three drug-free TCs at the end of the year [15]. In conclusion, the aim of this editorial is not solely to question critically the actual position of the TC in the field of addiction, but rather to insist on a future that enables the preservation of its identity while enhancing professionalism and embracing new challenges and rigorous research. The identity of the TC relies on a socio-psychological vision of the individual who moves in stages towards recovery and a drug-free life [16], and on a regular review of its practices and reasons for existence.