Donald J. Kurth, MD, MBA, MPA, FASAM CHAPTER
61

CHAPTER OUTLINE

The modern addiction therapeutic community (TC) is a powerful therapeutic tool that, over the past several decades, has helped hundreds of thousands of addicts and alcoholics achieve abstinence-based recovery (1). Abstinence rates of more than 90% for many years after treatment are documented in well-established TCs.

Historically, the TC has been used to treat a variety of problems in living, but the modern addiction TC or “concept TC” is a hybrid of self-help and public support geared toward the treatment of addictive and co-occurring psychiatric disorders.

The philosophic foundation of the modern TC is personal responsibility for one’s behavior and the belief that change is fully possible if the individual exerts the personal effort to follow the teachings of the program.

Evolving out of Alcoholics Anonymous (AA) in the 1960s, the modern addiction TC still retains many of the underpinnings of the 12-step approach to treatment. Drug addiction is viewed as a “whole person” disorder and, therefore, is treated with a holistic approach. Emotions and feelings are considered important and can be explored in depth, but change is based on action. That action is the responsibility of the individual. As in the 12-step recovery, the individual is not expected to walk this road alone. The community is available to help the addict at every step of the way.

In the TC philosophy, drug or alcohol use is considered a symptom of a complex disorder involving the whole person. Self-destructive and defeating patterns of behavior and thought processes are thought to disrupt both the individual’s lifestyle and society’s functioning. Though genetic, environmental, and pharmacologic contributions to addiction are recognized, the individual is held fully responsible for his or her own disorder, behavior, and recovery. Addiction is regarded as the symptom, rather than the disorder. The problem is the behavior of the person, not the drug.

HISTORY AND EVOLUTION

The modern TC is a new application of an ancient concept. The Dead Sea Scrolls found at Qumron document the first TC. The communal practices of an ascetic religious sect, perhaps the Essenes, include the “Rules of Community.” The Essene code denounces “the ways of the spirit of falsehood” and speaks of the problems of greed, lying, cruelty, brazen insolence, lust, and “walking the ways of darkness and guile.” Righteous and healthy living required strict adherence to the rules and teachings of the community.

Violation of the Rules of Community incurred sanctions resembling, though much harsher than, the sanctions used in the modern addiction TC. For violations, such as lying, bearing a grudge, foolish speech or laughter, sleeping during a community meeting, or leaving a community meeting, sanctions could include periods of banishment from the community or limited rations or privileges.

At about the time Jesus walked the earth, a group of healers (therapeutrides) of the “incurable” diseases of the soul lived in Alexandria, Egypt. Philo Judaeus (25 BC to 45 AD) described the group as professing “an art of medicine for [excessive] pleasures and appetites … the immeasurable multitude of passions and vices” (2). As in the modern TC philosophy, diseases of the soul were seen as manifesting themselves through the whole person. Healing was regarded as occurring through some form of community involvement.

The Washingtonians (founded by a group of drinkers) later appeared in the United States as a 19th century precursor to AA. Though the Washingtonians did not survive as a group, several of their methods are still apparent in the modern addiction TC. These include the commitment to abstinence, proselytizing its message to others, and the practice of self-appraisal during group meetings.

The conceptual and organizational lineage of the modern addiction TC began about 1921 with the Oxford Group—also known as The Buchmanites, the First Century Christians Fellowship, and Moral Rearmament (3). A branch of the Oxford Group in Akron, OH, evolved into AA in 1935 under the guidance of Bill Wilson and Doctor Bob Smith. A Santa Monica, CA, AA group evolved into Synanon in 1958 under the guidance of AA members. From Synanon sprang Daytop Village in New York City, under the guidance of Monsignor William O’Brien. From Daytop, more than 100 other therapeutic communities have developed around the world.

The Oxford Group (or Oxford Movement) began in the second decade of the 20th century as the First Century Christian Fellowship. Founded by the Lutheran evangelist minister Frank Buchman, the early Oxford Group preached a return to the purity and innocence of the early church. This spiritual rebirth was to be applied to all forms of human suffering. Though alcoholism and mental illness were not the primary focus of the Oxford Group, they were certainly seen as signs of spiritual deficit and thus were encompassed by the Oxford Group’s principles.

The Reverend Buchman headquartered the Oxford Movement in New York City, where Dr. Samuel Shoemaker, a pastor of Calvary Episcopal Church, became involved as well. During this period, the philosophies of the Quakers and Anabaptists (precursors to the Mennonites and Amish) began to influence the movement. These early influences carry through to the foundation of the modern addiction TC. Concepts and practices such as the work ethic, mutual concern, and sharing guidance are basic to the TC philosophy. Evangelical values such as honesty, purity, unselfishness, love, making amends for harm done, and working well with others all can be traced to this era (4,5).

The thread continues even today. Though not directly related to the Oxford Group, “Oxford House” is the name of a self-run, self-supported sober-living housing initiative that was begun in Silver Spring, MD, in 1975 and now includes more than 450 sober-living houses situated throughout the United States.

The 12 steps of AA evolved directly from the 6 steps of the Oxford Group. Together with the Twelve Traditions and the Twelve Concepts, the 12 steps embody the principles that guide the individual in recovery. The concepts of confessing to others and making amends and the belief that the individual change requires conversion to belief in the group are principles derived directly from the Oxford Group. Other AA principles include admitting one’s loss of control over alcohol and surrendering to one’s “Higher Power,” performing self-examination, seeking help from one’s Higher Power in changing one’s self, making amends to others, praying in the personal struggle, and helping others to engage in a similar process. Some striking differences are found, however. AA deviated from the Oxford requirement of a religious God by allowing each AA member to develop his or her own concept of a Higher Power. Though AA does not require a Christian god, its principles do stress that one’s power to change is derived from a power greater than one’s self. Nonsectarian AA, in fact, allows the Higher Power to be the AA group. This concept of the group as Higher Power is further developed in Synanon and later TCs, as it evolved into reliance on self and group process as the medium of individual behavioral change.

Fifteen years before Synanon appeared on the scene in the United States, however, psychiatric hospital TCs began to develop in Great Britain. Pioneered by Maxwell Jones, the first of these appeared as a social rehabilitation unit at Belmont Hospital in England in the mid-1940s. The Jones TC embraced the therapeutic nature of the total environment as a treatment tool (Table 61-1). Though the Jones TC is used today as a viable treatment method in Great Britain, its application to the treatment of addictive disorders occurred only in the context of dual-diagnosis patients. Some addictive disorder treatment adaptation of the Jones TC model has occurred in the United States in the Veterans Administration hospitals. There are little data about the efficacy of treatment in this application.

The evolution of Synanon from an AA group resulted in the concepts, program model, and basic practices that have become the essential elements of all modern addiction TCs. Synanon’s charismatic founder, Chuck Dederich, integrated his AA experiences with other philosophic, pragmatic, and psychological influences to create the Synanon program. The unique encounter group process (“the game”) evolved from weekly AA meetings. Distinct psychological changes were evident as a result of this process. The participants recognized this change as a new form of therapy and, within a year, the weekly meetings expanded into a residential community. In August 1959, the organization was officially founded to treat any addict, regardless of the chemical of choice. The name Synanon apparently was coined during the confused mumbling of a heroin addict who was having trouble pronouncing the word “seminar,” fusing it with the word “symposium.” Despite its role in the evolution of the modern TC, Synanon never considered itself a TC but rather an alternative community for teaching and living.

Synanon evolved from AA, and, as a result, the precepts of AA are fundamental to Synanon and to all modern addiction TCs. Still, the evolution did occur, and the differences are what created the TC as a distinct approach. Self-help recovery, a belief that the ability to change and heal lies within the individual and a belief that healing occurs as a result of a therapeutic relationship with others who have a similar affliction, all are philosophies common to both programs. The AA traditions and program activities led directly to the TC’s individual self-reliance, organizational self-reliance, and its schedule of regular groups and meetings.

The numbering system of AA’s 12 steps did not carry through to Synanon, but the same stages of recovery are very much a part of the Synanon program and the other modern addiction TCs as well. Steps 1 to 3 are embodied in the TC’s early-phase recovery, which emphasizes breaking through denial and engaging in the change process. Steps 4 to 9 are seen in the mid-phase recovery period of intense self-examination and socialization. This period involves taking a personal inventory, sharing confession with another person, and making amends. Steps 10 to 12 are reflected in the maturational process and increased autonomy that develop in the reentry phase of the TC. This phase requires continued personal honesty, humbly asking for help to sustain recovery, and actively helping others.

Critical differences, however, define the addiction TC as a new treatment modality. These include the residential setting, organizational structure, and profile of participants, goals, philosophy, and ideologic orientation.

Initially, residents could graduate from Synanon. Soon, however, Synanon (like AA) abandoned the concepts of graduation or completion of the program. In AA, when participants are fully integrated in society, they continue to participate in the program of recovery and continue to attend group meetings. This participation is analogous, perhaps, to continuing to attend church. In the case of 24-hour-a-day residential Synanon, completion of the program signified quite a different situation. All activities of a person’s life were to occur within the highly structured hierarchical organization, with no sort of reentry or reintegration back into society as a whole. Synanon embraced AA’s Seventh Tradition of fiscal independence with entrepreneurial spirit, developing profit-making businesses as well as pursuing both public and private funding. Though any member could rise within the hierarchy, the management was never democratic but rather oligarchic.

THE DAYTOP MODEL

Monsignor William O’Brien, a young priest, and Dr. Daniel Casriel, a Manhattan psychiatrist, first attempted to apply the concept of a TC specifically to the treatment of drug addiction. With the help of Joseph Shelly, chief probation officer of Brooklyn, NY, and Alexander Basson, a doctoral student who wrote the first grant, funds were obtained from the National Institute on Mental Health to develop an addiction TC.

The new program needed a director, and none of the initial applicants had been willing to take the job. So, Basson called the New York office of AA. A gentleman with no experience in treating drug addiction named Dean Colcord was sent to apply and was hired as the first director of Daytop Lodge (later to become Daytop Village).

Daytop Lodge opened with 25 beds on September 1, 1963, in Staten Island, NY. Dean Colcord had spent 3 weeks visiting the Westport Synanon to learn how it operated. Daytop applied the Synanon program with a strong dose of AA to the public sector treatment of addiction.

The founding of Daytop marked a milestone in the development of the modern TC (Table 61-2).

The modern TC rests on a foundation of secular ideology with certain existential assumptions, including the following:

■   Self-determination: A core value is self-determination. Each individual is seen as the captain of his or her own ship and the one who determines the path of his or her life.

■   Individual responsibility: The TC philosophy holds each individual fully responsible for his or her own behavior. No matter the genetic predisposition or environmental or family influences, each person is seen as fully and completely responsible for his or her own behavior.

■   Self-change: The concept of self-change is regarded as possible through personal commitment and adherence to recovery teachings.

FEATURES OF THE MODERN THERAPEUTIC COMMUNITY

The addiction TC is a powerful tool for changing behavior, and its efficacy is well documented in the literature. It is less clear how and why this therapeutic modality is so effective in changing difficult behaviors for which so many other methods are not successful.

Components of a Therapeutic Community Program

George DeLeon, PhD has written the seminal text on the TC, The Therapeutic Community: Theory, Model and Method (2000). Much of the following material has been adapted from the writings of George DeLeon and from the author’s own experience. Several features characterize TC programs that follow the Daytop Village model and other first-generation TCs (6) (Table 61-3). Although the components of the modern therapeutic community are described separately for educational purposes, it is important to emphasize that the therapeutic community is more than the sum of its component parts. While individual parts can be identified, in the spirit of community, those parts lend each other a synergy. It is their union and that synergy that creates community and gives the therapeutic community its powerful healing potential.

Community Separateness

TC-oriented programs have their own identities and are housed in a space or locale that is separated from other agency or institutional programs or units or generally from the drug-related environment. In residential settings, clients remain away from outside influences 24 hours a day for several months before earning the privilege of a brief visit to the outside community. In nonresidential “day treatment” settings, the individual spends 4 to 8 hours a day in the TC environment and is monitored by peers and family while outside the TC. Even in the least restrictive outpatient settings, TC-oriented programs and components are in place. This is designed to help members gradually detach from old networks and relate to the drug-free peers in the program.

A Community Environment

The TC environment prominently features communal spaces and collective activities. Walls carry signs declaring the philosophy of the program, the messages of right living, and recovery. Cork boards and blackboards are used to identify all participants by name, seniority level, and job function in the program. Daily schedules are posted as well. These visuals display an organizational picture of the program that the individual can relate to and comprehend, thus promoting program affiliation.

Community Activities

The TC philosophy holds that, to be effective, treatment and educational services must be provided within a context of the peer community. Thus, with the exception of individual counseling, all activities are programmed in collective formats. These activities include at least one daily meal prepared, served, and shared by all members; a daily schedule of groups, meetings, and seminars; jobs performed in teams; organized recreational/leisure time; and ceremonies and rituals (to mark birthdays, phase/progress graduations, and the like).

Staff Rules and Functions

Staff members are a mix of self-help professionals who are themselves in recovery and other helping professionals (medical, legal, mental health, and educational), who are integrated through cross-training grounded in the TC perspective and community approach. Professional skills define the function of staff members (e.g., nurse, physician, lawyer, teacher, administrator, case worker, clinical counselor). Regardless of professional discipline or function, however, the generic role of all staff members is that of community members who, rather than providers and treaters, are viewed as rational authorities, facilitators, and guides in the self-help community method.

Peers as Role Models

Members who demonstrate the expected behaviors and reflect the values and teachings of the community are viewed as role models. Indeed, the strength of the community as a context for social learning relates to the number and quality of its role models. All members of the community are expected to be role models: roommates; older and younger residents; and junior, senior, and directorial staff. TCs require these multiple role models to maintain the integrity of the community and to ensure the spread of social learning effects.

A Structured Day

The structure of the program relates to the TC perspective, particularly the view of the client and recovery. Ordered activities conducted in a regular routine counter the characteristically disordered lives in which clients have lived and distract from negative thinking and boredom—factors that are thought to predispose individuals to drug use. Structured activities also are regarded as facilitating the acquisition of self-structure on the part of the individual, as expressed in time management; planning, setting, and meeting goals; and general accountability. Thus, regardless of its length, the day has a formal schedule of therapeutic and educational activities with prescribed formats, fixed times, and routine procedures.

Work as Therapy and Education

Consistent with the TC’s self-help approach, all clients are responsible for the daily management of the facility (e.g., cleaning, meal preparation and service, maintenance, purchasing, security, scheduling, preparation for group meetings, seminars, activities). In the TC, the various work roles mediate essential educational and therapeutic effects. Job functions strengthen affiliation with the program through participation, provide opportunities for skill development, and foster self-examination and personal growth through performance challenge and program responsibility. The scope and depth of clients’ work depends on the program (e.g., institutional vs. free-standing facility) and client resources (levels of psychological function, social and life skills).

Phase Format

The treatment protocol, or plan of therapeutic and educational activities, is organized into phases that reflect a developmental view of the change process. Emphasis is placed on incremental learning at each phase, so as to move the individual to the next stage of recovery.

Therapeutic Community Concepts

Formal and informal curricula are focused on teaching the TC perspective, particularly its self-help recovery concepts and view of right living. The concepts, messages, and lessons are repeated in the various groups, meetings, seminars, and peer conversations, as well as in readings, signs, and personal writings.

Peer Encounter Groups

The principal community or therapeutic group is the encounter, though other forms of therapeutic, educational, and support groups are employed as needed. The minimal objective of the peer encounter is similar to TC-oriented programs—to heighten the individual’s awareness of specific attitudes or behavior patterns that need to be modified. However, the encounter process can differ in degree of staff direction and intensity, depending on the client subgroups (e.g., adolescents, prison inmates, and the dually diagnosed).

Awareness Training

All therapeutic and educational interventions involve raising the individual’s awareness of the effects of his or her conduct and attitudes on himself or herself and the social environment and, conversely, the effect of the behaviors and attitudes of others on the individual and his or her environment.

Emotional Growth Training

Achieving the goals of personal growth and socialization involves teaching individuals how to identify feelings, express them appropriately, and manage them constructively through the interpersonal and social demands of communal life.

Planned Duration of Treatment

The optimal length of a full program involvement must be consistent with the TC goals of recovery and its developmental view of the change process. How long the individual must be involved in the program depends on his or her phase of recovery, though a minimum period of intensive involvement is required to assure internalization of the TC teachings. The duration of treatment of the traditional therapeutic community generally is 12 to 18 months. Despite the established therapeutic success and cost-effectiveness of TCs at these durations of treatment, financial and bureaucratic pressures have forced TCs to attempt to progressively shorten their treatment stays. Initially, this appeared to be successful. But as treatment stays became shorter and shorter, it became more and more difficult to maintain the earlier rates of treatment success. While every treatment modality must be cost-effective in this day and age, there appears to be no doubt that when shortened beyond a certain point, the therapeutic benefit of the TC drops off dramatically (35).

Recent Emphasis of Building Early Retention

To some extent, the traditional TC model relies on the individual to come with some level of inherent motivation. Outside factors such as family pressure, probation, parole, and financial factors may contribute to this motivation. Absent these sorts of factors, however, the TC must help the individual to develop the motivation to change if treatment is to be successful. Increasingly, the process of engagement has become a key component of treatment.

Continuity of Care

Completion of primary treatment is a stage in the recovery process. It is followed by aftercare services, which are an essential component of the TC model. Whether implemented within the main program or separately (as in residential or nonresidential halfway houses or ambulatory settings), the perspective and approach guiding aftercare programming must be continuous with that primary treatment in the TC. Thus, the views of right living and self-help recovery and the use of a peer network are essential to enhance the appropriate use of vocational, educational, mental health, social, and other typical aftercare or reentry services.

Increasingly, facilitating involvement in 12-step programs has become popular, as well as long-term monitoring and support for former clients who have fully reentered the community. Some TCs offer varying levels of case management to help former clients in negotiating with community agencies and organizations.

Using the Community as the Therapeutic Method

At first blush, the therapeutic community appears to have much in common with other forms of residential treatment. Unique to the TC, however, is the fact that the community itself is the method by which the entire individual is treated.

DeLeon (4) describes method as all of the “activities, strategies, materials, procedures, and techniques” that are called into play to create the desired change in the individual in treatment. As the individual participates in the TC, the elements or basic components (Table 61-4) of the method become incorporated into the individual as the tools of therapeutic change. These basic components include member roles, membership feedback, membership as role models, relationships, collective learning formats, culture and language, structure and systems, open communications, and community and individual balance.

The European Experience: Expecting More Than the TC Can Give?

The success and therapeutic power of the TC model have not been lost on the international community. Literally hundreds of culturally appropriate TCs are scattered across the globe. The European experience, however, is worth examining.

As the success of the TC in Europe became recognized, governments began to place broader demands upon the TC model. Required staffing evolved from relatively inexpensive TC trained former addicts to much more expensive licensed counseling professionals and medical personnel the costs began to skyrocket. Over time, more challenging clientele with more serious mental, psychological, and medical problems were expected to be successfully treated in TCs that were even more restricted in their duration of treatment. Government requirements began to supersede the administrative and therapeutic decisions of the knowledgeable TC professionals, and treatment costs soon became unsustainable, finally resulting in the abandonment of the TC model in several European countries in favor of weaker but cheaper treatment alternatives (17). Unfortunately, trends in the United States appear to be following a similar pattern.

REFERRAL CRITERIA

For the physician in office-based practice, either as an addiction medicine specialist or simply as a perceptive, caring physician willing to address patients’ addictive disorders, a question often arises as to which type of treatment is most appropriate for a particular patient. This question may not be easy to answer but may well be the critical step that makes the difference between life and death for that particular human being.

Any one of four specific characteristics would qualify an addict and/or alcoholic for treatment in a TC (Table 61-5). But just what does such a person look like? Though a complete answer to this question could fill a volume or more, a few examples may serve to illustrate the broad outlines of the characteristics that might define a patient as a good candidate for treatment in a therapeutic community.

Case 1

The first example involves a patient who is abusing drugs or alcohol and who has begun to experience negative consequences of those behaviors but still is able to stop such use when the negative consequences are pointed out. For example, a young woman drinks only two or three times a year but has three wine coolers at the office Christmas party and perhaps even a joint offered by a coworker. If stopped for driving under the influence, such an individual may seek help for the problem, either on her own initiative or through a referral from the courts. Such an individual may not in fact be addicted to alcohol or drugs and probably can stop drinking and using on her own if she understands that negative consequences are directly and causally related to her substance use. She certainly does not need to participate in a long-term residential treatment program such as a TC.

Case 2

Another case involves a 44-year-old engineer who began drinking in college and has continued to drink heavily throughout his adult life. His family life may be stressed, but he still is married. His children are adolescents and not home very much. He may have had a DUI arrest 10 years earlier and, as a result, attended AA meetings briefly. But he found that he could not tolerate all the talk about God and Higher Power, so he drifted away from the meetings and continued to drink.

He was regarded as someone with high potential at the time he finished engineering school 20 years earlier, but he has not lived up to those expectations. He is resentful of his employer for not promoting him as he feels he deserves. His employer, on the other hand, is on the verge of firing him because he seems to have trouble making it to work on Mondays, especially after long weekends. He drinks six to eight vodka martinis every day when he gets home from work. However, he generally does not drink in the morning, except on the weekend. He does not consider himself an alcoholic.

Outpatient treatment probably will not be effective for this patient. He already has been to AA and found that it did not apply to his situation. If he is even slightly ready to change, he probably can do very well in hospital-based detoxification followed by inpatient rehabilitation for 30 days or so. This detoxification should be followed by outpatient treatment in either a partial hospitalization or intensive outpatient treatment program, with perhaps the additional support of a sober-living home. Finally, gradual transition back to his own home and work responsibilities over several weeks would give this fellow a good chance to build a strong foundation for a program of recovery that can well last him for the rest of his life.

Again, though his life is beginning to fall apart at the seams, this individual still has a lot going for him. He has a house, family, job, finances, and probably some social life left intact. The rest can be repaired or resurrected simply by adding some consistent sobriety to the equation.

Case 3

A third example is a 27-year-old Puerto Rican male from Spanish Harlem in New York City who began using intravenous heroin at age 14. He was raised by his mother who is also a heroin addict. He has never met his father. He began using drugs at 9 when he began to associate with the local street gang and quickly advanced to snorting and later injecting heroin. He has been incarcerated multiple times and has been infected with hepatitis B and C. He is not HIV positive at this time. When he is not in jail, he currently lives with his common law wife and three children but does not work and provides little support for the family. He spends most of his time hustling for money on the street, and his lifestyle is heavily involved with illegal and sometimes violent activity.

This client would be a great candidate for TC treatment. Treatment mandated by the criminal justice system through probation or parole would be ideal to help provide the motivation necessary to help him achieve sobriety. In addition, he needs a chance to get away from the toxic environment in which he is enmeshed and an opportunity to regain some level of physically healthy living. While the socioeconomic cards may be stacked against him, he still has a reasonable chance at achieving long-term recovery and rebuilding his life. Those around him may benefit from his recovery as well. The potential societal and family benefits of his successful recovery cannot be overemphasized.

Case 4

A fourth patient is a 34-year-old dentist who began drinking in high school and smoked a little marijuana as well. He did well in college without working very hard but found that it was easier to study if he used cocaine occasionally for those all-nighters at final exam time. After finishing dental school, he took over his father’s dental practice and did well for a few years. After a skiing injury to his back, he began taking prescription Vicodin and later OxyContin for the pain. He has had three surgeries on his back but still has pain.

The state physician diversion program interceded after he was investigated for writing excessive prescriptions for narcotics in the name of his office manager, and he currently is in the state’s physician diversion program. He has completed three inpatient treatment programs. The first program was a 1-week detoxification program with outpatient follow-up. That program proved to be barely a bump in the road of the progression of his disease. The second program consisted of inpatient detoxification followed by 4 weeks of inpatient rehabilitation in the standard 12-step format. Finally, after urinalysis showed continued opioid use, his license was suspended, and he was referred to a 90-day modified TC (MTC) program that specializes in treating professionals.

He completed the program and did well for 6 months after treatment. Then, he began to use heroin intravenously, and again was found out through random urine testing. At this point, his wife and children have left him, and he is in the throes of a divorce. He no longer has health insurance, and his car has been repossessed. He is living in an apartment that his father has been paying for from his retirement income. The diversion program is about to revoke his license and discharge him from the program for failure to derive benefit from treatment. This person is an excellent candidate for a residential modern addiction TC. He is at high risk of death. He probably has hepatitis B and C and can contract acquired immunodeficiency syndrome if he continues in his current lifestyle. There is little or nothing left in his life to repair or resurrect. He is in need of a new lifestyle and renovation of his behavior patterns, which is exactly what a TC has to offer. He may be reaching a state of desperation necessary for him to make the commitment needed to succeed in the TC environment.

These examples illustrate the fact that treatment in a TC is not appropriate for every person with a drug or alcohol problem. The commitment of time, money, and surrender to the program is significant. What makes the dentist in Case 4 a good candidate for a TC is clear from that illustration. His life is in crisis, he is unable to maintain abstinence, his social and interpersonal dysfunction has permeated every aspect of his life, and he has begun to display the antisocial lifestyle typical of end-stage addicts.

If such a patient has the good fortune to cross paths with a physician who is perceptive and knowledgeable enough to refer him to an appropriate addiction TC, he may have a chance to survive. In fact, in some ways, he actually may have a better chance than someone such as the engineer in Case 2.

Many patients seem to do better with a little external motivation. In the case of the dentist, the state diversion program may impose some requirements that will help him to remain focused on his recovery while going through the tough times of personal redevelopment in the TC process.

Requirements imposed through probation or parole orders can be helpful as well. Such requirements may sound harsh but are appropriate when balanced with the fact that the patients have a fatal illness and have failed at every other form of therapy. Admission to a TC may be the only defense between the addict and death in the street.

Outcome Studies

George DeLeon’s (4) pioneering efforts brought credibility and fundability to the TC model (see Appendix). Hubbard et al. (7) (Fig. 61-1) found that even those who did not achieve complete abstinence showed significant improvement in term of frequency of drug use, illegal activity, full-time work, and psychiatric factors. The work of Simpson et al. (8) (Fig. 61-2) showed that longer lengths of stay in residential treatment resulted in dramatically better outcomes over a variety of parameters.

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