Section X The Therapeutic Community

In discussing the role of methadone maintenance, reference has been made to the therapeutic community as the approach which stands most strongly today for treatment with a drug-free goal. Because of the importance which the therapeutic community has assumed in the debate concerning the proper approach to treatment, some further observations on this approach are appropriate. There have been, and there continue to be, strong differences of view between those who favour the therapeutic community and those who favour other approaches to treatment or management, in particular, methadone maintenance.

We examined the therapeutic community in some detail in our Treatment Report, and while we indicated certain limitations and cited some critical appraisal, we came, generally speaking, to favourable conclusions. We recommended that the Federal Government encourage the development of this form of treatment as "one option available in any national multi-modal drug-dependence program". We did not, as some have suggested, take the view that the therapeutic community was the preferred form of treatment in all cases of drug dependence. In the case of opiate dependence we expressed the view that methadone maintenance "provides to date the cheapest and most effective weapon we have for dealing with large-scale heroin dependence". In the case of dependence on the intravenous use of amphetamine or 'speed', however, we expressed the opinion that "Small therapeutic communities, restricted to speed users, offer the best hope for successful treatment and rehabilitation".

Since our Treatment Report there have been some critical appraisals of the therapeutic community that have tended to emphasize the limited nature of its role in the treatment of drug dependence. In a report prepared for the Bureau of Narcotics and Dangerous Drugs of the U.S. Department of Justice, McGlothlin and his associates stated that:

Even if therapeutic communities were made widely available, admission requirements reduced, and no competing treatments existed, it is doubtful if more than 10 per cent of the addict population could be maintained in this modality.'

The Consumers Union report on Licit and Illicit Drugs was even more critical, suggesting that support for the therapeutic community had been positively misleading, and had given people false expectations as to the possibilities of cure.2 The Ford Foundation report Dealing with Drug Abuse suggested that "it would be surprising if careful evaluation showed that more than five per cent of those who come into contact with the [therapeutic community] are enabled to lead a reasonably drug-free, socially productive life."3 As so often in these areas of uncertainty and controversy, there has been something of action and reaction.

Everyone is agreed that a major difficulty in coming to sound conclusions about the therapeutic community is that there is very little reliable data on which to base evaluation. Generally speaking, therapeutic communities have not encouraged such evaluation. They tend, understandably enough, to emphasize the total numbers who remain drug-free for a reasonable period of time, rather than the comparatively small proportion of the drug-dependent population who are attracted to the therapeutic community in the first instance and the large proportion of those who drop out of the program or "split" after a short time. In a field in which it is so difficult to effect cure, any cures are noteworthy and welcome, whatever their number. Critics of the therapeutic community are concerned, however, about its relative yield in relation to its cost. Because of the low numbers involved, particularly the number of those who "graduate", and the need for residential facilities, the therapeutic community is an expensive form of treatment, although it is less expensive than incarceration or hospitalization. Its cost does, however, invite a much closer look at its efficacy.

While we recommend continued support for the therapeutic community as one alternative in a multi-modal approach to treatment, we do so with recognition of its relatively limited role but also in the conviction that it is our duty, as a society, to make the most effective means of pursuing the difficult goal of abstinence sufficiently accessible to those who wish to pursue it. Obviously, it is more difficult and costly to pursue the goal of abstinence than it is to apply the policy of opiate maintenance. But we must continue to encourage the goal of abstinence and to hold it out as a real possibility, and for this it is necessary to maintain sufficient therapeutic community facilities. It is not an either-or proposition; we must have both opiate maintenance and therapeutic community. (Moreover, as we have said elsewhere, the therapeutic community does not exclude some acceptance of methadone maintenance.)

A report on "414", a residential therapeutic community run by the Addiction Research Foundation in Ontario, suggests that experience with the therapeutic community as a form of treatment of the adolescent user of `speed' has been somewhat discouraging.4 The report indicates that about 85 per cent of those who enter drop out or 'split' before the completion of the program, and that because of the restlessness and desire of adolescent residents to return to the outside world it is very difficult to implement the idea of a peer controlled therapeutic community, which is one of the main characteristics of the Synanon model. Indeed, there may be some conflict between the goal of re-entry into society, recommended in our Treatment Report and now more and more widely accepted by therapeutic communities and funding agencies, and the goal of maintaining some continuity of leadership by experienced members of the community. The report on "414" also stresses the phenomenon of "burn out" which is discussed in Appendix M Innovative Services. There is no doubt that constant contact with young persons dependent on 'speed' is an exhausting experience, and there must be realistic assumptions concerning the need for a regular renewal of staff after fairly short periods. The report suggests that the functional life of a staff member in such a community is between twelve and eighteen months, and that a staff member should not be expected to commit himself for much longer than a year.

The report on "414" contains this sombre conclusion concerning the efficacy of the therapeutic community in the treatment of the adolescent abusers of amphetamines:

Based on what we already know, however, we have severe reservations about whether therapeutic communities are the answer for effective treatment of this population. We find the financial costs to be high, and the human costs in terms of staff "burning out" to be considerable. The high rates of splitting especially after very short periods of time in the program contribute heavily to costs and make it unlikely that significant benefits are derived by these residents. The greatest positive changes in residents, we expect, will be found among graduates who comprise less than 15 per cent of persons who enter the program. (And, it is not always clear that many of these persons would not have significantly improved had it not been for their experience at "414". Our follow-up study should help clarify this point.) [Pp. 20-21.]

Our comment on these observations is that we are not surprised by the difficulties that have been encountered. The question is whether we have anything better for the intravenous user of amphetamine or 'speed'. The truth is that this form of drug dependence appears to be the most difficult to treat or manage, since we do not have an acceptable form of maintenance for amphetamine dependence nor, as yet, a fully satisfactory and operational antagonist. If the therapeutic community cannot succeed then we frankly do not know what can. We suspect that the best results are still to be obtained by a one-to-one relationship with an inspirational human being, where that can be developed. Meanwhile, we believe that we should continue to apply the technique of the therapeutic community as effectively as possible, accepting the fact that the results will continue to be fairly disappointing. Once again, we must offer the opportunity, for those who are prepared to take it, to escape from amphetamine dependence.

There has been a considerable increase in the number of therapeutic communities in Canada in the last year or so. Appendix H on Treatment Capacity in the Provinces contains a list of some 28 therapeutic communities, with a total residential capacity of slightly over 600, as of February 1973. Many of these have received financial assistance from the Federal Government through the Non-Medical Use of Drugs Directorate. At the time of our survey many of these communities were operating under capacity. The total number of persons in residence was under 400. Thus, it is far from clear how much more capacity of this kind, if any, is required in Canada to meet the potential for the therapeutic community approach to treatment. As we suggest, however, in Section VIII General Observations Concerning Treatment, this operation at apparent under-capacity may be due in many cases, not to a lack of need or demand for the therapeutic community form of treatment, but to an insufficiency of qualified staff.

There is now recognition of the necessity of reintegration into the general community and a greater emphasis, as there must be, on the need for evaluation of results. Such evaluation calls for follow-up on graduates in the general community for a period of several months or even years to assess their performance in terms of the goals of abstinence from harmful drug use and social rehabilitation. The overall goal is sometimes described as the development of a "positive life style" reflected in abstinence from dependence-producing drug use and criminal activity, stablized accommodation, school attendance or stable employment, and satisfactory personal and social relationships. Such evaluation will always involve a large measure of subjective judgment, but the obligation to evaluate and to render some accounting will encourage the development of a self-critical attitude and the disposition to make necessary changes in approach from time to time. It is doubtful if there can ever be satisfactory comparative evaluation of the results achieved by the therapeutic community and other forms of treatment or management. Apart from a difference of goals in many cases, there is the difficulty of establishing suitably matched control groups. We simply have to accept the fact that the therapeutic community is a form of treatment which offers some reasonable hope for the person who seeks to become abstinent, and as such deserves its place in a multi-modal treatment program. At the same time, we must be mindful of its relative cost in our total allocation of financial resources for the treatment or management of drug dependence.

NOTES
1. W. H. McGlothlin, U. C. Tabbush, C. D. Chambers and K. Jamison, "Alternative Approaches to Opiate Addiction Control: Costs, Benefits and Potential," Paper prepared for the U.S. Department of Justice, Bureau of Narcotics and Dangerous Drugs, February 1972, mimeographed, p. 40.
2. E. M. Brecher & the Editors of Consumer Reports, Licit and Illicit Drugs: The Consumers Union Report on Narcotics, Stimulants, Depressants, Inhalants, Hallucinogens, and Marijuana—Including Caffeine, Nicotine, and Alcohol (Boston: Little, Brown, 1972), p. 82.
3. P. M. Wald & P. B. Hutt, Dealing with Drug Abuse: A Report to the Ford Foundation (New York: Praeger, 1972), p. 195. Further, Smith and Gay in "It's so good don't even try it once" observed that:
Out of every hundred who seek help in a "[therapeutic] community" program, more than 90 are rejected at the door or leave the program after only a few weeks. Of those who remain, 80-90 per cent remain heroin-free and crime-free for at least one year. [Englewood Cliffs, N.J.: Prentice-Hall, 1972, p. 10.]
4. R. C. Brook & P. C. Whitehead, " `414': A Therapeutic Community for the Treatment of Adolescent Amphetamine Abusers," Unpublished manuscript, London, Ontario, January 1973.