Veerle Soyez

The Third Generation of Therapeutic Communities: The Early Development of the TC for Addictions in Europe

Aims: It is the goal of this study to investigate the first development of the drug-free therapeutic community (TC) in Europe. The paper aims at systemizing information, scattered all over Europe and is the first stage in an ongoing study to record the development of the European TC movement and its influences. Design: After a study of the grey (hidden) literature, TC pioneers and experts per country were contacted to further elaborate the first findings. Subsequently, a preliminary summary of our findings was published in the Newsletter of the European Federation of Therapeutic Communities (EFTC), inviting additional information and corrections. The authors completed the results for this article with relevant first-hand information, obtained through interviews with European pioneers. Findings: The findings are summarized under three topics: chronology, interconnections and European identity. It was found that from 1968 until 1989, a new therapeutic approach arose all over Europe, modeled after Synanon, Daytop and Phoenix House, New York, through Phoenix House, London and Emiliehoeve in the Netherlands. Therapeutic communities were established in Belgium, Finland, Germany, Greece, Ireland, Italy, Norway, Spain, Sweden and Switzerland as well. These communities were closely-knit and interconnected in their reaction against psychiatric and methadone treatment. The European TCs developed an own identity compared to the American ones. Conclusions: The European TCs adapted the model of their American predecessors to their own culture, influenced more by milieu-therapy and social learning. Instead of harsh behaviorism, more emphasis was placed on dialogue and understanding. Professionals occupied a more pivotal role and took over the dominant position of ex-addicts. Research, executed by TC professionals gradually entered the TC. A generic network of TC connections, through which the development evolved, was uncovered, and clear regional trends can be observed.

Mentally ill offenders in prison: The Belgian case

According to the EUPRIS-study on mental health in prisons (2007), available data on mental disorders in prison are scarce. Therefore, this study aims at summarizing and discussing the available knowledge on incarcerated mentally ill offenders concerning: (1) the screening and assessment for detecting mental health; (2) the psychiatric expertise in order to evaluate the mental status; and (3) the development and provision of forensic psychiatric treatment and care. These findings will be applied to the current situation in Belgium, which is a particularly interesting case. Belgium is currently facing difficulties concerning a large population of interned mentally ill offenders residing in correctional establishments. Implications with regard to the penal code, general or mental health legislation, screening, assessment, and treatment could deliver interesting viewpoints on how this problem could be tackled more effectively. Therefore, the findings will be discussed with reference to the international scientific and policy debate, focusing on ethical implications.

Essential Elements of Treatment: A Comparative Study Between European and American Therapeutic Communities for Addiction

The purpose of this study was to investigate whether European and American therapeutic communities (TCs) for addiction, both traditional and modified, share a common perspective on what is essential in treatment using the Survey of Essential Elements Questionnaire (SEEQ). The European sample (N = 19) was gathered in 2009. For the American sample (N = 19), we used previously published research data. Despite comparable perspectives, European traditional TCs (N = 11) scored significantly higher than their American predecessors (N = 11) on four SEEQ domains. Cluster differences were more pronounced in Europe than in America.

Addiction severity predictions using client network properties

By statistical analysis of client data it is shown how past or current network information together with other knowledge assesses treatment needs. The main findings are as follows. The client’s previous exposure to addicts in the family has almost no influence on his or her present contacts with addicts in daily life. About 30% of the clients have experienced addicts both in family and among friends, about 30% have only family exposure, about 20% have neither kind of exposure, and about 20% have no family exposure but have current exposure to addicts. Exposure to addicts in family implies a higher risk of severe need for professional intervention than no such exposure. For the clients with no family exposure but with current exposure to addicts there is, somewhat surprisingly, a lower risk than for the other three categories of clients. This effect seems to be mainly because the psychiatric status of these clients is somewhat better than for those in the other three categories. The effect disappears if we look solely for drug addiction intervention needs; then there is a clear increase in relative treatment needs for the categories with previous or present addiction exposure compared to those without.

Therapeutic Communities, Family Therapy, and Humanistic Psychology: History and Current Examples

This article discusses the use of residential therapeutic communities (TCs) to help addicts recover. The European and American antecedents of the TC and the model’s further evolution and dispersion are described. The increasing openness of the TC toward the outside world and its changed attitude toward family involvement have played important roles in the evolution of the TC. In this context, the article also pays attention to the family approach in the early TC and the major family therapeutic schools that influenced the model, specifically contextual therapy. A renewed attention to its humanistic roots can preserve the TC from becoming just another substance abuse treatment modality. However, good functioning of the TC as humanistic organization also requires openness, professionalism, and scientific input. Those elements are as safeguards against destructive charismatic leadership and insularity.

How do substance abusers and their significant others experience the re‐entry phase of therapeutic community treatment: a qualitative study1

Transition to re-entry (aftercare) is a stressful event for therapeutic community residents. While several authors agree on the importance of social support during reintegration, few studies have focused on the experiences of re-entry clients themselves and their significant others during this period. Using a case-study design, the present study examines the re-entry process of four TC-residents and three of their social network members during a six-month period, starting at the time of their transfer to the halfway house. Clients and their significant others have mixed feelings about the reintegration period, although both are mainly positive. Clients report difficulties in leaving behind the TC-mentality and building up a stable social network; they are surprised about the frequent contacts with substance (ab)use in mainstream society. Significant others misjudge clients’ feelings about transition and relapse. Many significant others have a positive attitude towards the use of substances. The tendency in mainstream society to increasingly accept the use of substances intensifies clients’ need for early guidance in building up stable supportive networks. Significant others need well-grounded information on the reintegration process and on relapse.

The Role of Gender Differences and Other Client Characteristics in the Prevalence of DSM-IV Affective Disorders Among a European Therapeutic Community Population

There is a lack of research illustrating the extent of psychiatric problems in European TCs. Furthermore, there is a need to obtain more insight into gender differences concerning comorbidity in the TC population. In an attempt to respond to previous shortcomings, three specific goals were formulated for the current study. The primary aim was to explore the lifetime prevalence of affective disorders in European TC clients. The second aim was to focus on related gender differences. And finally, client characteristics measured by the EuropASI were related to mood and anxiety disorders measured by the SCID-I. Nine out of ten substance abusers treated in a European TC program have an affective disorder. Gender differences are noted for two anxiety disorders: men have more obsessive-compulsive disorders; women have more post-traumatic stress disorders. The study illustrates that not only gender but also other client characteristics should be taken into account when organizing treatment.

Implementing ASI and other instruments to professionalize treatment across national borders: experiences from the IPTRP project

This paper describes experiences of implementing different standardized assessment tools for research and treatment needs in 29 residential treatment centres in nine countries in Europe, within the IPTRP (Improving Psychiatric Treatment in Residential Programs for emerging dependency groups). Four instruments were obligatory for all centres participating: the EuropASI, the SCID, the Maastricht Social Network Analysis MSNA and the BioMAPS. The implementation process was prolonged, since extensive and repeated training was needed and the instruments had to be translated and adapted, and comparability in data discussed. The data collection had to deal with both coding and language problems before any analysis could be made. The experiences show several prerequisites for the success of this kind of project: an understanding of the treatment framework as a system, to anticipate and plan for problems and blockages; active involvement of staff in the project and intensive training, consultancy and support.

Treatment perspectives on interned mentally ill offenders in a forensic psychiatric center (FPC): a Delphi study on experts' opinions

The study aims to map the treatment perspectives of international experts on treating mentally ill offenders (MIO) in a forensic psychiatric centre (FPC) using the Delphi method. The four-round Delphi study reveals high conformity on the proposed treatment-related issues. However, some points of divergence remain. Three controversies underpinning these disagreements are discussed. The first regards the treatment and control debate, the second concerns the dual role of assessment in forensic mental health care and the third describes potential entry conditions for treatment in a FPC. Further research is needed to scientifically underpin the above mentioned debates. In this regard, the study suggests a close collaboration between practitioners and researchers.

Barriers to Implementation of Treatment Guidelines for ADHD in Adults With Substance Use Disorder

Objective: Attention deficit hyperactivity disorder (ADHD) is common among adult patients with a substance use disorder, yet often goes undetected. This is a qualitative study to explore implementation barriers to a guideline developed in Belgium for the recognition and treatment of ADHD in adult patients with substance use disorder and to gain a better understanding of the strategies to overcome these barriers. Methods: Focus groups were conducted with caregivers and patients to explore experiences with comorbid substance use disorder and ADHD. The barriers reported in these focus groups became the subject of further study in focus groups with addiction professionals (physicians, psychiatrists, and psychologists) who had tried the guideline and with psychiatrists specializing in addiction but without experience with ADHD. Results: Our analysis revealed a number of barriers to the implementation of this guideline, including lack of information from the family, pressure from patients and caregivers to make an ADHD diagnosis, and the potential for abuse of ADHD medication. Furthermore, diagnostic instruments for ADHD have not been validated in people with substance use disorder. Although patients with ADHD are usually treated in an outpatient setting, patients with ADHD comorbid with substance use disorder are difficult to identify in an outpatient setting for various reasons. Finally, there is a lack of specific ADHD expertise in substance use treatment organizations. Conclusions: Despite the availability of an approved guideline for recognizing and treating adult ADHD in patients with a substance use disorder, underdiagnosis and inadequate treatment still persist. As in general substance use treatment, medication only plays a supportive role in the treatment of substance use disorder with comorbid ADHD. An integrated approach and further improvements in the competence of practitioners may help to reduce the resistance to diagnosing ADHD in substance use treatment centers. Practitioners who specialize in addiction medicine and therapists without medical education view the problem from different perspectives and therefore each group needs specific information and training. Targeted interventions need to be developed to keep these patients in treatment.