George De Leon, Ph.D., is an internationally recognized expert in the treatment of substance abuse and is acknowledged as the leading authority on research in therapeutic communities. In addition to numerous research publications, Dr. De Leon has made notable contributions in the area of clinical practice and professional education. He provides training in therapeutic community practice to psychiatric fellows, psychologists, nurses, social workers, and other health care professionals in treatment programs. Dr. De Leon is Director of the Center for Therapeutic Community Research in New York City, and Research Professor of Psychiatry at New York University. Michele Bellasich, from Dianova in Sweden met with him during the WFTC world conference, November 5th - 10th, in Bali (Indonesia)
How did you come up with the idea of implementing Recovery Oriented Integrated Systems?
The Recovery Oriented Integrated System(ROIS) was designed as a response to the marginalization of the TC treatment model. Funding pressures have dramatically reduced the planned duration of treatment, a policy which contradicts the science documenting the relationship between retention and outcomes in TC studies. The ROIS is a paradigm of a systems approach. It emphasizes partnership linkages among community providers to coordinate transitional and aftercare treatment and social services.
There is an increasing interest on recovery oriented integrated systems ; I first developed this approach because I wanted to provide continuous assistance to individuals in treatment, particularly to those coming out of therapeutic communities (TC). Most service providers already know a lot about aftercare and re-entry for example, however they usually do from the standpoint of a particular program or re-entry program, rather than thinking about the fact that the individual has to actually leave the program and continue his recovery in the world separated from the program.
I then began to realize that the original formulation of the therapeutic community approach – which included re-entry – could be a base for guiding policies and developing systems. Our current systems are generally designed to manage disease rather than promote recovery. The idea was thus to build a policy that would consider how to reformulate a system so that it be recovery oriented, with a good understanding of what recovery stages are, and where individuals have what they need to move to the next stage of their own recovery.
Is the therapeutic community treatment model evidence-based?
Despite decades of Therapeutic Community (TC) outcome research, policy makers, funders, and even many scientists still question whether the TC is an evidence-based treatment for addictions, in particular when comparing it to some pharmacological treatments or very limited behavioral treatments like motivation and cognitive behavioral therapy, which are not programs per se but single-dimension treatment models.
However, we must recognize the limits of the evidence we have: we do have considerable research but we still face a relative lack of randomized, double-blind control trials and this is the reason why it is often asserted that the effectiveness of the TC treatment model has not been “proved” – assertions which may have serious implications for the acceptance, and future development of, TCs.
Actually, the weight of the direct research evidence from all sources and over many years, in many countries supports the conclusion that the TC is an effective and cost-effective treatment model, especially with the most challenging populations – those with severe drug use, social and psychological problems. In a recent issue of The International Journal of Therapeutic Communities (1), entirely devoted to the evidence of therapeutic communities, I wrote an article which summarizes this evidence, while the remainder of that edition is dedicated to address other, specific areas, including comparative, cost-based studies, effectiveness of TCs in United States’ prisons, and that of the modified TC for persons with co-occurring substance use and mental disorders.
Most critics continue to base their opinion on randomized studies only. This is a serious epistemological problem in science – one science cannot argue with another about what is evidence or not. Of course, we should make a full-blown effort and try develop randomized controlled studies in a genuine attempt to develop more evidence of TC effectiveness – and this could make a great contribution to social science research – however they are particularly difficult to develop because of the difficulty to meet the basic criteria which pertain to this type of studies.
Let me be clear about it: I do not think that attempting to make those studies is the right thing to do; I think that we have to do them simply because they have been identified as our weakness. If we are able to develop randomized controlled studies, they might provide the ultimate proof of effectiveness of the therapeutic community treatment model.
If we can’t, we would therefore have to change the whole perspective of science, while gaining the acceptance of the massive amount of evidence which has been developed over the years.
In Sweden, where I work, addiction professionals are more and more concerned about the issue of co-occurring disorders and other problems substance abusers usually face, like social exclusion. How should we address this problem according to you?
Your question has multiple issues. A client coming into treatment generally face multiple problems, and you have only a short period of time to treat him. This is a problem that everyone is facing, in all treatment approaches, including therapeutic communities.
After a fifty-year work experience in TCs, we know that we have to adequately define the particular subpopulation that we are treating. We have to know what kind of problem an individual entering the program has to face in addition to substance abuse: a psychological or psychiatric problem, such as schizophrenia, or a social problem such as homelessness and poor education.
Our strategy of treatment should be to try focus on the substance abuse problem while addressing the other problems as well. Another critical point is that you have to properly assess the subgroup you are dealing with in order to provide a treatment response which is based on this evaluation.
The next important element is the duration of the treatment and the treatment setting. As you know, when talking of residential programs, we refer to the setting, the place where the program is taking place. Most frequently, therapeutic communities utilize residential settings, but not necessarily. We should then start thinking about defining the place or the setting which may optimize the use of the therapeutic community.
The research has been very clear about this issue: when confronted to a severe substance abuse problem, a residential setting is best indicated – at least at the beginning of the treatment program – to help clients stabilize. This 3 or 4-month period of time will help you identify the extent of the clients’ co-occurring problems, while thinking about what will be the next placement for them. You should build a system approach in order to keep them in continuity, for example utilizing a modified, residential therapeutic community followed by a six-month period in a supportive housing capable of providing additional support for people with mental health needs.