Vanderplasschen, Wouter

Vandevelde, Stijn

English

Ghent University Academic Bibliography

Wege aus der Sucht6The Synanon model quickly spread across the United States and gave rise to the first ‘concept’ TCs for drug addicts (e.g. Daytop Village, Phoenix House, Odyssey House) (Goe-thals et al., 2011). These drug-free, peer-led environments adopted Synanon’s hierarchical structure and therapeutic techniques and set a three-stage treat-ment model (detoxification/induction, treatment, reintegration). ‘Drug-free’ or ‘concept’ TCs, later called TCs for addictions (De Leon and Ziegenfuss, 1986), have been defined as «drug-free environments in which people with ad-dictive problems live together in an or-ganised and structured way to promote change towards a drug-free life in the outside society” (Broekaert et al., 1993, p. 55). Not all residential treatment pro-grammes are TCs and not all TCs are organised and delivered in a residential setting (Broekaert et al., 1999). Moreo-ver, not all programmes self-identified as TC programmes employ the same The therapeutic community (TC) is one of the longest standing modali-ties for the treatment of drug addic-tion, dating back to Synanon, a com-munity of ex-addicts in California. Background, current state and future of therapeutic communities for addictions in Europe[1]theory, model or method.  The TC is essentially a living and learning setting, which means that resi-dents are totally immersed in the treat-ment environment, so that all of their daily behaviour and their emotional and physical state can be observed and chal-lenged as appropriate through intensive group experiences (Vanderplasschen et al., 2014). In addition, they are encou-raged to experiment with alternative behaviours and corrective emotional experiences. Thus, the TC can be regar-ded as «a consciously-designed social environment and programme within a residential or day unit, in which the social and group process is harnessed with therapeutic intent” (Roberts, 1997, p. 4). Or like George De Leon, one of the main proponents of the international TC movement, asserts: «In the TC, the community is the primary therapeutic instrument.” (De Leon, 2000, p. 93). The concept of ‘community as method’ or the «purposive use of the peer community to facilitate social and psychological change in individuals” is central to the TC treat-ment practice (De Leon, 1997, p. 5). Resi-dents, in collaboration with staff, become active participants in their own therapy and that of other residents (Glaser, 1981). From the 1960s and 1970s onwards, TCs were developed in Europe, e.g., in the United Kingdom (Phoenix House), Italy (e.g. CeIS), Germany (e.g. Daytop Germany), Switzerland (e.g. Aebi Hus), and Belgium. Later, TCs were founded in Spain, Norway, Greece, Austria and some east European countries (e.g. Poland and the Czech Republic) after the fall of the Iron Curtain. Its development took place in a period characterised by increased availability of heroin and other illicit substances and lack of effective treatment responses. The heroin epide-mic in the mid-1980s resulted in a rapid spread of infectious diseases, mainly HIV/AIDS, and a dramatic growth in the number of drug-related deaths. Around this time, TCs started to lose their domi-nant position in treating drug users as several countries, including the UK, Netherlands and Switzerland, embra-ced the harm reduction approach for reducing the negative health and social consequences of drug use (Hedrich et al., 2008). TCs also faced other challenges, such as financial cutbacks as a result of the economic crisis, questions about high dropout and relapse rates and changing drug policies primarily aimed at redu-cing drug-related harm. Problems with charismatic leadership in TCs in some countries (e.g. ‘Le Patriarche’ (France), Vallmotorp (Sweden)) and the switch from self-funded, independent organisa-tions to mainstream services that are fun-ded and controlled by the government led to the closure of some TCs and their replacement with smaller communities run by professionals instead of ex-addicts (Vanderplasschen et al., 2014). Changing views on addiction as a chronic, relapsing disorder and increasing criticism on the benefits of lengthy treatment in closed residential settings by scientists, client advocates and service users have further challenged the development of TCs in several  countries. Finally, the evidence-based paradigm that applies the rando-mised controlled trial (RCT) as ‘gold standard’ for evaluating interventions has questioned the efficacy of TCs, as TCs scored low in an (outdated) meta-analysis of case management (Smith et al., 2006) and in comparative ‘evidence-based’ rankings (Broekaert et al., 2010). Yet, several systematic reviews have demonstrated the effectiveness of TCs, in particular regarding substance use and criminal justice outcomes, mediated by length of stay in treatment (retention) and subsequent aftercare participation (De Leon, 2010; Vanderplasschen et al., 2013).TCs in Europe todayAlthough essentially inspired by the US TCs, European TCs clearly have their own identity; there was strong opposi-tion to the hard learning techniques such as wearing signs and shaving hair — the so-called haircuts — and the extremely von Wouter Vanderplasschenund Stijn Vandevelde[1]  This contribution is based on Vanderplasschen, W., Vandevelde, S. & Broekaert, E. (2014). Therapeutic Communities for Addictions in Europe: Evidence, current practices and future challenges (EMCDDA Insights Series). Luxembourg: Publications Office of the European Union. Wege aus der Sucht 7harsh confrontations in encounter groups (Goethals et al., 2011). The Ame-rican behaviouristic approach was com-plemented by European educational the-ories, psychoanalytical thinking, social learning, involvement of trained profes-sionals (instead of recovered ex-addicts serving as staff members) and more family-oriented approaches (Broekaert et al. 2006). TCs from various European countries collaborate in the European Federation of Therapeutic Communities (EFTC; http://www.eftc-europe.com/) and emphasize the importance of TC standards and quality control.  Over the last 50 years, TCs have evol-ved from the standard, long-term, gene-ric treatment model to modified and shortened models (modified TCs) that are better tailored to the needs of spe-cific groups of drug users, e.g. women with children, detainees and individuals suffering from other psychiatric disor-ders (Goethals et al., 2011). According to several sources the availability of TC pro-grammes has decreased in several Euro-pean countries, such as the Netherlands, Sweden, Switzerland and the United Kingdom (Broekaert and Vanderplass-chen, 2003), mainly due to the relatively high cost of long-term treatment. How-ever, there are also national and cultural factors at play, as different countries have shaped unique drug treatment provision landscapes and therefore given different degrees of prominence to TC treatment. In order to estimate the extent of TC treatment in Europe, the European Moni-toring Centre for Drugs and Drug Addic-tion (EMCDDA) commissioned a study on current evidence and TC practices in Europe in 2012 (see Vanderplasschen et al., 2014). In total, we identified over 1 200 TC programmes throughout Europe; only in Turkey and Croatia the TC was not applied as a treatment method. Two-thirds of the identified programmes were reported from Italy (n = 798), with the Italian experts describing most of these programmes as small, family-type structures with a capacity of four to six residents, but adhering to international TC guidelines and standards. Outside Italy, we identified just over 400 facili-ties providing TC treatment. While the number of TC programmes is low in one in three countries (<5), it seems to be a well-established treatment modality in the south of Europe (e.g. Greece, Spain, Italy, Portugal) and in some East Euro-pean countries (e.g. Lithuania, Hungary, Poland). Countries like Austria, Belgium and the Czech Republic report around 10 TCs, or about 1 TC programme per one million inhabitants. Key informants from these countries reported sustainability issues in terms of public funding for TCs, resulting in the shutdown of some TCs in Norway and the UK, reductions in treatment duration (e.g. Czech Republic, Spain, Finland) and the number of beds per unit (e.g. Latvia, Sweden). France is a clear exception in this sense, as TCs for addictions have recently been re-established. The capa-city of TC programmes varies greatly, but is usually between 15 and 25 resi-dents. The number of treatment slots per unit is clearly higher In some countries (e.g. Cyprus, France, Poland, the United Kingdom). Overall, the number of places for drug addicts in TC programmes in Europe was estimated to be over 15 000 beds (Vanderplasschen et al., 2014).  The estimated number of TC resi-dents per year in each country is indi-cative of the turnover and average treatment duration. In most countries, TC programmes last between 6 and 12 months and the number of residents (persons retained in the TC for at least one night) per year is twice the available capacity. In some countries, this rate is considerably higher (e.g. Poland, Fin-land), due to the high turnover and/or short length of (some) TC programmes. The low resident turnover in other coun-tries (e.g. Austria, Belgium, Ireland) may be explained by high retention rates and adequate induction strategies to prepare drug addicts for TC treatment. Future of the TCThe effectiveness of TCs has been and will be further questioned. Longitudinal studies and systematic reviews are nee-ded to document the (cost-)effectiveness of these long-term interventions (Van-derplasschen et al., 2013). The future of TCs is likely to depend on how well these programmes continue to target areas where they can make the most impact and achieve the most good at adequate costs. This means continuing the imple-mentation of modified TC programmes for particularly vulnerable populations, such as homeless persons or those with co-existing disorders, as well as establi-shing TCs in prison settings. While posi-tive outcomes from prison-based TCs have been reported in the US literature, these findings may not be directly trans-lated into the European context.  Seite 31 Despite the strained relation between abstinence-oriented and harm reduction programmes previously, today TCs, psy-chiatric services, substitution and harm reduction initiatives are increasingly becoming better attuned to each other. In fact, they serve the same clients and methadone maintained persons can access residential TC treatment. While maintenance treatment has proven its effectiveness with respect to health conditions, quality of life and use of illi-cit drugs, TCs can look to the long-term perspectives of reintegration, social inclusion and abstinence. The TC movement has become re-conciled to approaches that advocate the introduction of shorter programmes and outreach and community-based in-terventions. For example, the length of the residential treatment phase has been reduced in most countries to around 9 to 12 months or less. A gro-wing emphasis on expenditure contain-ment is likely to contribute to further reductions in the planned duration of TC treatment, as well as a number of other possible changes to the TC model and the way it is practised. This includes an emphasis on the role of volunteers and self-help elements at the expense of ‘professional’ staff members. The ways in which the quantity and, more impor-tantly, the quality of the TC interven-tion are negotiated will determine its future role in addiction treatment. Governmental control and adhe-rence to standards such as the stan-dards and ethics code formulated by the World Federation of TCs (WFTC) pro-vide a general framework for TC profes-sionals. For accreditation purposes and continued quality control, however, more detailed standards are necessary and the set of ‘Service Standards for Addiction Therapeutic Communities’ developed by the Community of Com-munities (CofC, 2012a, b) is an encoura-ging example. Although quality control in TCs in most countries is limited to staffing issues, TCs themselves appear to be open to more in-depth and com-prehensive assessment and accredita-tion of their services. In conclusion, TC programmes for the rehabilitation of drug users are es-tablished in many European countries and play an important role as part of national addiction treatment systems. There is some evidence for the effec-tiveness of TCs in terms of reduced sub-stance use and criminal activity, at least Wege aus der Sucht 31in the US and a culture of TC research is being developed in Europe. It is vital to maintain this type of treatment to sup-port recovery of drug addicts, in particu-lar for individuals with long-lasting and complex problems. ReferencesBroekaert, E. (2006). What future for the Thera-peutic Community in the field of addiction? A view from Europe. Addiction, 101, 1677-1678.Broekaert, E., Autrique, M., Vander-plasschen, W. & Colpaert, K. (2010) The human prerogative. Questions on the integration of evidence-based, existential and social critical paradigms of care in substance abuse treatment. Psychiatric Quarterly, 81(3), 227-238.Broekaert, E., Kooyman, M. & Ottenberg, D. (1993). What cannot be changed in a thera-peutic community? Orthopedagogische Reeks Gent 2, 51-62.Broekaert, E., Raes, V., Kaplan, C.D. & Coletti, M. (1999). The design and effectiveness of therapeutic community research in Europe: An overview. European Addiction Research, 5, 21-35.Broekaert, E. & Vanderplasschen, W. (2003). Towards the integration of treatment sys-tems for substance abusers: Report on the Second International Symposium on Substance Abuse Treatment and Special Target Groups. Journal of Psychoactive Drugs, 35(2), 237-245.Broekaert, E., Vandevelde, S., Soyez, V., Yates, R ., Slater, A. (2006). The third generation of therapeutic communities: The early development of the TC for addictions in Europe. European Addiction Research, 12, (1), 1-11.Community of Communities (CofC) (2012a). Our values and standards. Retrieved from: http://www.rcpsych.ac.uk/quality/quality-andaccreditation/therapeuticcommunities/com-munityofcommunities/ourvaluesandstandards.aspx. De Leon, G. (1997). Community as method. Therapeutic communities for special populations and special settings. Westport, C.T.: Greenwood Publishing Group, Inc. De Leon, G. (2000). The therapeutic community. Theory, model and method. New York: Springer.De Leon, G. (2010). Is the Therapeutic Com-munity an Evidence-based Treatment? What the Evidence Says. International Journal of Therapeutic Communities, 31(2), 104-128.De Leon, G. & Ziegenfuss, J. (1986). The-rapeutic communities for addictions: Readings in theory, research and practice. Springfield, IL: Charles C. Thomas.Glaser, F.B. (1981). The origins of drug-free therapeutic communities. Addiction, 76(1), 13-25.Goethals, I., Soyez, V., Melnick, G., De Leon, G. & Broekaert, E. (2011). Essential elements of treatment: A comparative study bet-ween European and American therapeutic com-munities for addiction. Substance Use & Misuse, 46, 1023-1031. Hedrich, D., Pirona, A. & Wiessing, L. (2008). From margin to mainstream: The evolu-tion of harm reduction responses to problem drug use in Europe. Drugs: Education, Prevention and Policy, 15(6), 503-517.Kennard, D. (1994). The future revisited: New frontiers for therapeutic communities. Therapeutic Communities, 15(2), 97-102.Roberts, J. (1997). How to recognise a thera-peutic community. Prison Service Journal, 111, 4-7.Smith, L . A ., Gates, S. & Foxcrof t, D. (2006). Therapeutic communities for substance related disorder. Cochrane database of systematic reviews, 1: DOI: 10.1002/14651858.CD005338.Vanderplasschen, W., Colpaer t , K ., Autrique, M., Rapp, R .C., Pearce, S., Broekaert, E. & Vandevelde, S. (2013). Therapeutic communities for addictions: a review of their effectiveness from a recovery-oriented perspective. The Scientific World Journal, 2013, Article ID 427817.Vanderplasschen, W., Vandevelde, S. & Broekaert, E. (2014). Therapeutic Communi-ties for Addictions in Europe: Evidence, current practices and future challenges (EMCDDA Insights Series). Luxembourg: Publications Office of the European Union.Wouter Vanderplasschen (PhD)is associate professor at the Department of Special Needs Education (Orthopedagogiek) of Ghent University (Belgium). He is a senior researcher in the field of addictions, recovery and mental health. His main research interests are substance abuse, case management, therapeutic communities, vulnerable groups, and evaluation of interventions. Seite 7 Peergroup in Bezug auf Medienkonsum. Einen bedeutenden Faktor stellen darüber hinaus intrafamiliäre Konflikte dar (vgl. Wölfling et al. 2013). Da viele Computer-spiele ihre Schwierigkeit an das Können der Spielenden anpassen und die volle Aufmerksamkeit der Spielenden fordern, können sie dabei helfen, unangenehme Empfindungen in den Hintergrund zu rücken. So kann exzessives Spielen auch ein wichtiger Hinweis auf zugrunde lie-gende familiäre Konflikte sein. In diesem Sinne wäre ein suchtartiges Computer-spielverhalten eher als dysfunktionale und vermeidende Copingstrategie denn als eigenständiges Krankheitsbild zu ver-stehen. BewertungDas Familiensystem ist sowohl bei der Prävention als auch bei der Behandlung suchtartigen Spielverhaltens einzelner Mitglieder ein zentrales Element. Eltern, die ein Problembewusstsein haben und selbstständig aktiv werden, finden Anlaufstellen sowohl im beraterischen (z. B. www.fachstelle-enter.at, www.bupp.at, www.saferinternet.at) als auch im thera-peutischen Kontext (z. B. www.ambulanz.sfu.ac.at, www.api.or.at). Schwieriger ist es natürlich, Familien zu erreichen, die Helfersystemen kritisch gegenüberste-hen und freiwillige Angebote nicht in Anspruch nehmen. Sinnvoll wäre hier, indirekt über MultiplikatorInnen zu wir-ken und LehrerInnen sowie Fachkräfte in der Kinder- und Jugendhilfe auf spezi-fisch medienpädagogische Aufgabenstel-lungen hin zu schulen.Grundsätzlich halte ich es für eine gesamtgesellschaftliche und somit po-litische Aufgabe, auf Phänomene exzes-siven Computerspielens und den Stel-lenwert, den das Medium vor allem bei einer jüngeren Zielgruppe einnimmt, adäquat im Sinne von Präventionsmaß-nahmen zu reagieren. Bis dies geschieht, sind Familien mit diesem Thema auf sich allein und auf eine vor allem au-ßerhalb Wiens sehr dünn gesäte Bera-tungs- und Therapielandschaft gestellt.LiteraturGee, J. (2010): What Videogames have to teach us about learning and literacy. Palgrave Macmillan, New York.Kammerl, R. et al. (2012): EXIF – Exzessive Internetnutzung in Familien. Studie im Auftrag des BMFSFJ, Berlin.Petry, J. (2016): Computersüchtig? Pathologischer PC/Internetgebrauch als neues Störungsbild. In: Archiv für Wissenschaft und Praxis der sozialen Arbeit, Heft 1/2016.Puhm, A./Strizek, J.  (2016): Problematische Nutzung von digitalen Spielen: Forschungsbericht. Gesundheit Österreich, Wien.Wölfling, K. et al. (2013): Computerspiel- und Internetsucht. Ein kognitiv-behaviorales Behand-lungsmanual, Kohlhammer, Stuttgart. Seite 19 Markus Meschik, MAist Sozialpädagoge und leitet die Fachstelle für digitale Spiele »Enter« in Graz. Er ist Gutachter und Experte für die »BUPP« des Bundesministeri-ums für Frauen, Familien und Jugend und dissertiert zum Thema Sucht bei digitalen Spielen an der Karl-Franzens Universität Graz.

Background, current state and future of therapeutic communities for addictions in Europe

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Background, current state and future of therapeutic communities for addictions in Europe

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Ghent University Academic Bibliography