The drugfree therapeutic community Findings and reflections in an evidencebased era

1
The drug-free therapeutic
communityFindings and reflections in an
evidence-based era

• Mieke Autrique
• VAD
• Association for Alcohol and other Drug use

2
A challenge for TC's

• EBP important issue in discussions on quality of
  SAT
• Evidence-based medicine
• Problem-based learning
• Integration of
• Evidence
• Clinical expertise
• Client values and needs

3
A challenge for TC's

• Increasing demand of policy makers
• Concerns of treatment providers
• TC in Belgium request for article
• Discuss some issues on tension between and
  possible integration of EB paradigm and drug-free
  TC

4
A challenge for TC's

• Overview
• Methodological problems
• Evidence and TC's
• Towards more EBP in TC's

5
Methodological problems

• Several reviews on effectiveness of
  pharmacological and psychosocial interventions
• TC not much conclusive evidence available

6
Methodological problems

• A lack of evidence does not necessarily imply
  that this intervention is not effective
• RCT easy or difficult to measure
• Short term vs. longer term
• Comparison different interventions, insufficient
  implementation, experimental and control
  condition
• Relapse influences treatment outcomes

7
Methodological problems

• TC's specific complications
• Complexity of the treatment modality
• Heterogeneity research population
• High drop-out rate
• Differences in treatment goals, programme
  characteristics and outcome measures
• Definition of 'therapeutic community'

8
Evidence and TC's

• Length of time quality of staff members
  certain level or quality of research literature?
• Lack of emphasis in early days
• Lack of resources finance, staff, adequate
  research methodologies, designs and instruments
• Recent years changing attitude importance of
  evaluative research

9
Evidence and TC's

• First studies US early generation, mainly
  opiate addicts
• Beginning 1980s majority poly drug users. New
  studies needed.
• Policy makers increasing demand for evidence
• EWODOR and EFTC research tradition originated in
  Europe

10
Evidence and TC's

• 'Time in treatment' as most powerful predictor of
  succesful outcomes
• Drop-out highest first months introduction of
• 'Senior staff'
• Family and social network support

11
Evidence and TC's

• APA 'Practice guidelines for the treatment of
  patients with substance use disorders' (2006)?
• Opioid, cocaine, multiple SUD
• Multiple treatment failures
• Social relational employment
• Understanding readiness

12
Evidence and TC's

• 'Service Standards for Addiction Therapeutic
  Communities' (Shah Paget, 2006)?
• Core standards
• Physical environment
• Staff
• Joining and leaving
• Therapeutic environment
• Treatment programme
• External relations
• 'Ideal practice'

13
Evidence and TC's

• Cochrane review (Smith, Gates Foxcroft, 2006)?
• 7 RCT's US
• Little evidence that TC's significant benefits
  compared to other residential treatment or that
  one type better
• Methodological limitations no firm conclusions

14
Evidence and TC's

• vs. TC conception collection of 'good
  practices' to improve quality of life
• Bio-psychosocial approach
• Step-by-step process towards recovery
• Objectives of each intervention or component
  based on stage of recovery
• ? Difficult translation of EB paradigm into
  TC daily practice

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Towards more EBP in TC's

• Many positive but not enough reliable data.
  Position in treatment process?
• Need for good quality qualitative and
  quantitative research studies
• Towards a wider interpretation of 'evidence'
• Need for evidence-based guidelines

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Towards more EBP in TC's

• Keep pace with contemporary evolutions and
  challenges
• Specific target groups
• Integration with methadone programmes and HR
• Introduction of BI with family and social network
  support
• Shorter-term and non-residential programmes

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Towards more EBP in TC's

• Open, critical and reflective attitude vs.
  'therapeutic fundamentalism' in the past
• Individual client practitioner level
• Systematic assessment of client needs, providing
  answers, evaluation
• Critical assessment of working methods
• Keep up with new developments
• ? need for accessibility of evidence, training
  and education

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Towards more EBP in TC's

• Need for a constructive debate between policy
  makers, researchers and practitioners
• Clarification of implications for current
  practice
• Integration of different perspectives and
  conceptions of effectiveness
• Towards more quality of care in TC's

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References

• Autrique, M., Vanderplasschen, W., Broekaert, E.
  Sabbe, B. (2008) The drug-free therapeutic
  community Findings and reflections in an
  evidence-based era. Therapeutic Communities, 29,
  1, 5-15.
• Autrique, M., Vanderplasschen, W., Broekaert, E.
  Sabbe, B. Practitioners' attitudes concerning
  evidence-based guidelines in substance abuse
  treatment. European Addiction Research (accepted
  for publication, 14 July 2008)?