Hierarchical therapeutic communities: The jewel in the crown, or the poor relation among treatment approaches to chronic addiction?

Abstract

Since the formation of Synanon in 1958, the TC has proved to be an enduring and effective method of treating and rehabilitating addicted individuals. The TC subscribes to an holistic approach which sees addiction as a disease of the whole person. As such, the TC promotes social, psychological and spiritual development and thus offers the greatest potential for change when compared to other treatment modalities. The TC approach, despite its popularity, remains controversial. The harsh confrontation and encounter group methods often associated with TCs have been the focus of ongoing criticism. However, ample research bears testimony to the effectiveness of TCs with individuals for whom traditional treatment methods are of little value. The field of substance abuse treatment has proved enormously challenging. Despite the controversy and ongoing criticism aimed at the TC philosophy, it is unlikely that any other treatment modality (outside the 12-step programmes from which the TC grew) has had a greater impact upon the treatment and rehabilitation of addicted individuals. Perhaps due to the fact that TC philosophy remains outside the dominant medical paradigm, it has been omitted from large scale studies such as Project MATCH. While there is plenty of scope for improving the effectiveness of TC treatment, such developments will only occur as a result of the model's inclusion in unbiased, empirically-based research. A more broad-minded approach to such research is required where effective modalities are not excluded on the basis of their 'alternative' philosophies. While viewed as an expensive alternative to outpatient treatment, it should be noted that TCs tend to treat more difficult, hard-core addicts for whom outpatient treatment is not sufficient or appropriate. The alternatives for such individuals are invariably much more expensive and provide little or no therapeutic change. Hence, when the alternatives are considered, the TC actually represents great cost benefits.