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BackgroundThe Therapeutic Community (TC) is a common treatment modality for incarcerated individuals with substance use disorders. TCs rely on peer group processes to promote lasting behavioral and identity change, yet prior research has not adequately tested the peer influence mechanisms underlying the theoretical model. This study applied dynamic network analysis to estimate peer influence processes central to TC philosophy.MethodsA stochastic actor-oriented model (SAOM) was applied to ten months of social network data collected from prisoner surveys within a TC unit (N = 62) in a medium-security Pennsylvania prison. Respondents (N = 177, 84% of unit) completed at least one prison survey and provided network and community role model nominations.ResultsAlthough residents' levels of treatment engagement were significantly correlated with their nominated peers, estimates of peer influence for treatment engagement were non-significant in longitudinal network models. Nor were estimates of peer influence significantly greater for peers perceived as community role models. Rather, inmates connected with peers who were of similar treatment engagement as themselves (i.e., a peer selection process), and the latter primarily resulted from racial homophily in the TC social network.ConclusionsInconsistent with the desired treatment model, treatment engagement diffusion was not evident in the sampled TC. Results suggested that highly-engaged residents clustered together at the center of the TC's social structure but had little impact on less-engaged and peripheral inmates. The relatively short (i.e., four-month) program length and moderate-to-low treatment fidelity likely contributed to the lack of peer influence processes.

Therapeutic communities (TCs) have a strong record of maintaining high quality social climates in prison units. One possible reason for this is the system of mutual monitoring among TC residents, based on the assumption that peer affirmation of behavior in accord with TC norms, and peer correction of behavior contrary to TC norms, will lead to increased resident prosocial behavior. Laboratory experiments have demonstrated that such peer monitoring can lead to cooperation, but there has been no quantitative test of this hypothesis in an actual TC. In this article we test this assumption by using the affirmations that residents of three different TCs send as a measure of prosocial behavior following the reception of peer affirmations and corrections. At all three facilities residents send more affirmations following the reception of both affirmations and corrections, with this relationship being stronger and longer lasting after receiving affirmations. No other variable consistently predicts the number of affirmations that residents send to peers. These findings imply that mutual monitoring among TC residents can lead to increased levels of prosocial behavior within the facility, and that prosocial behavior in response to peer affirmations plays a key role. (Contains 4 tables.)

Describes the prevalence of sexual abuse among adolescents (N=938) admitted to residential therapeutic communities for treatment of substance abuse and related disorders. Results indicate that approximately one-third of the sample reported histories of sexual abuse. Prevalence rates were significantly higher for girls than for boys. History of sexual abuse is related to earlier onset of alcohol and illicit drug use. (Author/MKA)

Explores sequential assignment (SA) and treatment-as-usual (TAU) as two approaches to overcome many of the obstacles of random assignment in field studies of treatment efficacy. Substituting SA and TAU for the standard random assignment may introduce methodological impurities including certain limited biases. (SLD)

The therapeutic community (TC) has become an established treatment approach serving thousands of substance abusers in community, institutional, and other settings. This article summarizes the research that contributed to the acceptance and growth of TCs and laid the groundwork for the establishment of TCs for substance abusers in correctional settings. The TC knowledge base has contributed to the revival of a rehabilitation philosophy in correctional policy, which is described in the second section. The reflections of the authors who have collaborated for about 40 years are provided at the end of the paper.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jsat.2006.03.016 Byline: George De Leon (a), Gerald Melnick (a), Yan Cao (b), Harry K. Wexler (a) Keywords: Self-perception; Substance abuse; Recovery; Criminal justice; Recidivism Abstract: The present prospective study explored whether a specific class of client subjective assessments predicts later recovery. Measures of client perceptions of self-change in substance abusers were obtained a year after release from a prison-based therapeutic community. Analyses assessed the contribution of these perceptions -- along with motivation, age, and risk index of social deviancy -- in predicting reincarceration at 3-year follow-up. Results showed that two factors (Individual Growth and Socialization) significantly differentiated reincarceration and nonreincarceration at 1-year postrelease and significantly predicted reincarceration at 3-year follow-up. Findings underscore the relevance of perceptions of self-change early in recovery to later recovery behaviors. Research on recovery factors needs a uniform assessment protocol, which organizes client perceptions, beliefs, and attributions in accordance with a recovery stage framework. Author Affiliation: (a) National Development and Research Institutes, New York, NY 10010, USA (b) UCLA Integrated Substance Abuse Programs, Los Angeles, CA, USA Article History: Received 23 May 2005; Revised 21 February 2006; Accepted 22 March 2006

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jsat.2006.02.007 Byline: Veerle Soyez (a), George De Leon (b), Yves Rosseel (c), Eric Broekaert (a) Keywords: Treatment readiness and motivation; Assessment; Therapeutic communities; Psychometric properties; CMRS Abstract: There is empirical evidence that treatment motivation and readiness are closely linked to retention. Several instruments have been developed to measure these concepts; such instruments can reliably assess the stages of motivation and readiness, and predict treatment retention and outcome. However, limited efforts have been undertaken in Europe to translate those instruments and to determine their reliability and validity. In this study, the psychometric properties of a Dutch translation of the Circumstances, Motivation, Readiness, and Suitability (CMRS) scales by De Leon and Jainchill [Journal of Psychoactive Drugs 8 (1986) 203-208] and the shortened CMR Intake Version are illustrated in a Flemish sample of therapeutic community residents (n = 207). Exploratory factor analyses confirm three CMR subscales, although confirmatory factor analysis reveals only a moderate fit for both the CMRS and the CMR. In contrast, the predictive power of the instrument is strong, specifically for 1-year retention. Significant correlations were found between CMRS measures and age, drug severity, legal referral, and social problems. It is concluded that the Dutch translation of the CMRS and the CMR can be employed as a valid indicator of treatment motivation and readiness, although additional research concerning factorial structures is needed. Author Affiliation: (a) Department of Orthopedagogics, Ghent University, H. Dunantlaan 2, 9000 Gent, Belgium (b) Center for Therapeutic Community Research (CTCR), National Development and Research Institutes, Inc., 71 West 23rd street, New York, NY 10010, USA (c) Department of Data Analysis, Ghent University, H. Dunantlaan 1, 9000 Gent, Belgium Article History: Received 15 April 2005; Revised 16 January 2006; Accepted 8 February 2006

Although the largest effects of prison-based therapeutic community (TC) programs are associated with entry into aftercare, only a minority of prisoners volunteer for these aftercare programs. The study addresses the gap in our knowledge concerning these low rates of voluntary entry. A theoretical formulation of the TC process involving the effect of the interaction of clients' motivation and participation in the activities of the TC on entry into aftercare was tested on a sample of 110 volunteers in a prison-based TC for whom there were client and staff ratings of 3-month participation and 12-month follow-up data on relapse and recidivism. Path analyses support a model in which the interaction of motivation and 3-month participation ratings have a direct effect on the selection of aftercare, and aftercare has a direct effect on relapse and recidivism. The use of a combination of enhanced motivation and early program participation as a means of increasing the utilization and effectiveness of aftercare is discussed., Recent evaluation studies of prison-based substance abuse treatment programs have shown that the greatest benefits are associated with continued treatment in postprison aftercare (1, 2) or work release (3). These [...]

The present study is the first report on a client-treatment matching protocol (CMP) to guide admissions to residential and outpatient substance abuse treatment settings. Two cohorts, a field test sample (n = 318) and cross-validation (n = 407) sample were drawn from consecutive admissions to nine geographically distributed multisetting therapeutic communities (TCs). A passive matching design was employed. Clients received the CMP on admission, but agencies were 'blind' to the CMP treatment recommendation (i.e., match) and assigned clients to treatment by the usual intake procedures. Bivariate and logistical regression analyses show that positive treatment dispositions (treatment completion or longer retention in treatment)) were significantly higher among the CMP-matched clients. The present findings provide the empirical basis for studies assessing the validity and utility of the CMP with controlled designs. Though limited to TC-oriented agencies, the present research supports the use of objective matching criteria to improve treatment. Keywords: Client-treatment matching; Substance abuse treatment; Therapeutic communities; Effect of drug severity and social dysfunction; Length of stay

The therapeutic community (TC) Client Assessment Inventory (CAI), Client Assessment Summary (CAS), and Staff Assessment Summary (SAS) are instruments developed from a comprehensive theory of TC treatment and recovery. They measure client self-report and staff evaluation of client progress along 14 domains of behavior, attitude, and cognitive change. The present article reports on the development of the instruments and findings from an analysis of data on 346 clients in TC treatment; including scale properties and cross-sectional client differences by treatment tenure. The instruments were administered over a 1-year period at two residential TC facilities. Findings indicate that both client and staff instruments reliably differentiate client clinical changes during treatment and client self-ratings are initially consistently higher than staff ratings. Clarifying and measuring changes in the individual during treatment is the first step in the effort to understand the change process and what steps can be taken to improve treatment effectiveness. Keywords: Therapeutic community; Treatment process; Treatment progress; Clinical assessment; Assessment instruments; Psychometric evaluation

This study reports on the extent to which Therapeutic Community (TC) agencies share a common set of beliefs about the essential elements of TC treatment. The Survey of Essential Elements Questionnaire (SEEQ), a TC theory-based instrument, was used in a field survey of 59 directors of agencies identified as TCs through their membership in Therapeutic Communities of America (TCA). Results showed a high degree of concordance in the perceived importance of a common set of treatment elements identified as essential to the TC modality. Two clusters of TC-oriented agencies, identified as Traditional and Modified, were determined based on beliefs in the importance of the elements. Results were seen as validating the TC formulation from which the SEEQ items were drawn. Implications on the potential use of the SEEQ as a means of codifying TC treatment for research, training, and quality assurance are discussed. Keywords - drug abuse treatment; therapeutic community; treatment process.

We studied a modified therapeutic community designed for the treatment of patients with combined substance abuse and psychiatric disorders. This model has been ap 117117plied on a limited basis in clinical practice, and little is known about the characteristics of patients who are likely to complete the prescribed stay in such a program. In this report, we present characteristics of 189 homeless dually diagnosed men who entered a shelter-based, modified therapeutic community with a prescribed 6-month stay. Thirty-four percent of admissions completed the prescribed stay. These patients were more likely to have fewer inpatient psychiatric admissions and more job experience than those who did not complete their stay. Findings are discussed in terms of their similarities and differences to findings from traditional therapeutic communities for the singly diagnosed. Keywords-addiction; therapeutic community; dual diagnosis; homelessness; retention rate.

A growing body of research has demonstrated the importance of motivation and readiness among drug abusers in seeking, complying with, and remaining in treatment. To date, however, there is little research on these factors among adolescent substance abusers. The present study reports findings from a large scale investigation of motivation and readiness differences across adolescent (range = 14-18 years, n > 1000) and adult (range = 19-26+ years, n > 1400) admissions to residential therapeutic communities (TCs). Data were collected with an instrument assessing circumstances, motivation, readiness, and suitability for TC treatment (i.e., CMRS). Results showed that:(1) there is a significant positive linear relationship between CMRS scores and age; (2) the CMRS scores were the largest and most consistent predictors of short term retention across all age groups. Although confined to TC samples, the present findings support clinical observations that adolescent drug abusers are less motivated to change or ready for treatment than adults; and they confirm the importance of motivational and readiness factors in the treatment process, regardless of age., INTRODUCTION Clinical impression, recovery theory, and developing research underscore the importance of motivational and readiness factors among drug abusers in seeking, complying with, and remaining in treatment (1-3). These factors [...]

There is currently little empirical research on the effect of motivation and readiness on the treatment of different groups of substance abusers. In the present study, the CMRS scales are used to assess motivation and readiness for treatment of a large sample of primary alcohol, marijuana, heroin, cocaine, and crack cocaine abusers admitted to a long-term residential therapeutic community. Findings show few significant differences in overall retention or initial motivation and readiness. Initial motivation and readiness scores persist as significant predictors of short-term retention m treatment across most groups. Findings support the TC perspective that the substance abuse problem is the person, not the drug of choice, and are consistent with prior research emphasizing the importance of dynamic rather than fixed variables as determinants of retention., INTRODUCTION Motivation and readiness are viewed by clinicians as critical factors in understanding why substance abusers seek or stay in recovery oriented treatment regimes such as the TC. These factors [...]

Passages is a day treatment model based on therapeutic community (TC) methods adapted for methadone maintained clients. The goal of the program is to reduce cocaine use and injection, other drug use, and high-risk sexual behavior. The Passages approach is grounded in a recovery-oriented perspective in which methadone is a prescribed medicine that can facilitate a self help, recovery process. Preliminary evaluation findings on over 500 research participants indicate greater differential improvement in drug-risk behavior and psychological status for the Passages clients who remained 6 months in the program compared to non-Passages clients. Though awaiting controlled studies, the present study demonstrated the feasibility of integrating methadone maintenance and TC-oriented day treatment in methadone clinics; and provided evidence for the effectiveness of the Passages program in reducing risk behavior and improving psychological functioning among seriously dysfunctional substance abusers.

The limited survey data available suggest that therapeutic communities have increasingly organized themselves to develop HIV prevention programs and to integrate HIV-infected and AIDS clients into the treatment community while providing specialized program as necessary. Nonetheless, there remains a need for a comprehensive survey of the response of therapeutic communities to AIDS and the risk of HIV infection. There is need as well for studies that can build on findings linking retention in the therapeutic community to strategies that focus on clients' motivation or readiness for treatment. In addition, therapeutic community programs can ally with outreach programs both to provide priority admission to seropositive clients, women with children, adolescents, and criminal justice clients, and to provide harm reduction services to those unwilling to enter treatment while also taking incremental steps to engage those clients in ever increasing behavior change initiatives. Keywords - therapeutic community; HIV; drug abuse treatment; retention and motivation.

Family structure and function and their association with knowledge and attitudes toward sexuality, contraception, and sexually transmitted diseases (STD) were studied in 918 students and 312 adolescents working in factories. Unmarried workers reported higher rates of sexual activity than did students (30.9% vs. 21.8%, p = .04 for males; 12.9% vs. 6.0%, p = .005 for females). Among sexually active males, 33.3% of students and 30.7% of workers used contraception, compared with 27.5% of female students and 9.5% of female workers. Workers were from larger families than students, and the male and female workers had lower scores for knowledge on sexuality, contraception, and STD than did students. Multiple stepwise regression showed that age and schooling of the parents were associated with knowledge and attitudes in the students. In workers, the position of the child in the family was a negative regressor for attitudes and knowledge on sexuality in males, and for knowledge on contraception and STD in females. In regard to family function, the significant factors were compromise between the parents, positive affective response, communication within the family, problem solution, and control of behavior. It was concluded that female workers are at higher risk for unwanted pregnancies and STD. The factors associated with knowledge and attitudes were age, schooling of the parents, mother working out of home, position of the adolescent in the family, and the diverse aspects of family function., INTRODUCTION Complications of pregnancy and delivery are the main causes of death among adolescents in Mesoamerica (Suarez, Roberts, Korin, & Cuminsky, 1985). Surveys from such diverse countries as the United [...]

Based upon clinical considerations, scales were developed measuring client perceptions across four interrelated domains: circumstances (external pressures), motivation (intrinsic pressures), readiness, and suitability (CMRS) for residential TC treatment. This paper, the first in a series, reports findings on the reliability of the CMRS and its validity as a predictor of retention in TC treatment in three cohorts of consecutive admissions to a long-term residential TC. The main findings show that: (a) discriminant and factor analyses confirm the face validity of the original four rationale scales; (b) scores distribute into four groups, with most clients in the moderately low to moderately high range; (c) two cross-validation studies confirm the internal consistency of the scales, and a linear relationship between the separate and total CMRS scores and short-term retention in all three cohorts and long-term retention in two cohorts. The present psychometric study provides impressive findings on the reliability and validity of the CMRS scales as predictors of retention in long-term TCs. Although still considered experimental, awaiting replicational studies and firm conclusions concerning generalizability, the CMRS holds considerable promise for research, theory, and practice., INTRODUCTION Clinicians have long held the conviction that motivation, readiness, and perceptions of treatment are critical factors in understanding why addicts seek, remain in, and benefit from recovery-oriented treatment programs [...]

Intravenous drug use, which has been recognized as the second most common risk behavior associated with AIDS, was studied among methadone outpatients who were enrolled in a methadone program at a hospital-based clinic in New York City. Intercorrelations among the following variables were observed: sociodemographic, psychological, drug use patterns, and criminal history. Then a stepwise discriminant analysis was employed to examine factors differentiating the high risk clients from the lower risk clients in terms of needle use/sharing in the 30 days prior to the interview. The subjects (N = 152) were heterosexual (95%), non-White (63%), had no more than 12 years of education (72%), were not full-time employed (65%), and had been arrested at least once (79%). The median age at the time of entering the methadone treatment was 33 and the median length of stay in the treatment was 17.5 months (mean = 44.7 months), with an average 52 mg of methadone dosage. Results indicated that risk behavior in terms of current needle use/sharing occurred in about 16% of a sample of clients in the methadone maintenance. A shorter length of stay in treatment was the strongest predictor of high risk, followed by early arrest history, ethnicity, depression, and employment status., INTRODUCTION Approximately 30% of die AIDS cases reported to the Centers for Disease Control since January 1, 1988, have been intravenous (IV) drug users[1]. IV drug use is recognized as [...]

This exploratory study assessed the value of fixed and dynamic variables for predicting client retention in therapeutic communities. Fixed variables included demographic and background characteristics that had been used to predict client retention and outcomes in previous research. Dynamic variables included circumstances under which clients joined programs and their motivations for seeking treatment. The sample comprised 753 admissions to 5 traditional therapeutic communities for substance abusers. Although both fixed and dynamic variables predicted client retention, the strongest predictors were two dynamic variables. One was exaddict interviewers' predictions of whether clients would stay long enough in the program to benefit from treatment. The other was whether clients had spent most of their time with large groups of people, as opposed to spending most of their time with small groups or alone, before using drugs. Program and treatment variables need to be taken into account along with client variables to better understand and improve retention in therapeutic communities and other types of drug abuse treatment programs., The effects of fixed variables including demographic factors and background characteristics were compared with dynamic variables such as psychological status on predictingthe retention of 753 clients in five traditional therapeutic communities for substance abusers. Results showed that dynamic variables were more predictive of client retention than fixed client variables. The stronger predictors include interviewers' assessment whether client would stay in the program, whether clients spent most of their time with large groups of people and whether the client has been jailed prior to admission to the program.