Eigenvector centrality defines hierarchy and predicts graduation in therapeutic community units

Introduction Therapeutic communities (TCs) are mutual aid based residential programs for the treatment of substance abuse and criminal behavior. While it is expected that residents will provide feedback to peers, there has been no social network study of the hierarchy through which feedback flows. Methods Data for this study was drawn from clinical records of peer corrections exchanged between TC residents in six units kept over periods of less than two to over eight years. Four of the units served men while two served women. Hierarchy position was measured using eigenvector centrality, on the assumption that residents who were more central in the network of corrections were lower in the hierarchy. It was hypothesized that residents would rise in the hierarchy over time. This was tested using Wilcoxon paired samples tests comparing the mean and maximum eigenvector centrality for time in treatment with those in the last month of treatment. It was also hypothesized that residents who rose higher in the hierarchy were more likely to graduate, the outcome of primary interest. Logistic regression was used to test hierarchy position as a predictor of graduation, controlling for age, race, risk of recidivism as measured by the Level of Services Inventory-Revised (LSI-R) and days spent in the program. Results Residents averaged a statistically significantly lower eigenvector centrality in the last month in all units, indicating a rise in the hierarchy over time. Residents with lower maximum and average eigenvector centrality both over the length of treatment and in the last month of treatment were more likely to graduate in four of the six units, those with lower maximum and average eigenvector centrality in the last month but not over the length of treatment were more likely to graduate in one of the six units, while eigenvector centrality did not predict graduation in one unit. However, this last unit was much smaller than the others, which may have influenced the results. Conclusion These results suggest that TC residents move through a social network hierarchy and that movement through the hierarchy predicts successful graduation.

Good practices in Italian therapeutic communities. Outcomes 2020 of quality accreditation program “Visiting DTC Project”

Purpose This paper aims to present results achieved by the first, and to date only, Democratic Therapeutic Communities (DTC) quality improvement program developed in Italy, in the past 10 years, named “Visiting DTC Project.” Process of bottom-up identification, definition and evaluation of good practices of TCs for adult users with long term severe mental disorders will be described. In addition, a five-phase clinical care pathway will be presented for the same user category, developed by the “Visiting DTC Project” to comply with Italian National Health Service accreditation standards for TCs. Design/methodology/approach “Visiting DTC Project” involved 40 Italian TCs, since 2012 until 2020, in an action research on good practices developed throw a democratic and bottom-up methodology. Project’s methodology is the “Democratic Peer-to-peer Accreditation,” a kind of professional scientific quality accreditation and continuous improvement process for community mental health services. Scientific model for the definition of service standards and principles of treatment is the British “Democratic Therapeutic Community,” which the “Visiting DTC Project” is organizationally inspired by. Findings In the eighth annual cycle of the program for TC with adult users of mental health services a significantly effective good practice procedure (GPP), with good practical efficacy, was finally identified (for the first time after eight years), but still no best practice. GPP with the title “Multi-family Community Meeting” is the Good Practice of the year 2020. No Best Practice has yet been identified. An integrated clinical care pathway for Adult DTCs Users in five phases is also presented. This care pathway organizes advanced standards of Community Group Quality in a map, to support the description and planning of the five phases of the user’s clinical work in DTC treatment. Originality/value Cooperation with local community services, organizations and networks, as well as a therapeutic environment based on informal coexistence and cooperation between TC members, are thus, together with care of family relationships, the main characteristics of the Italian experience of implementing and developing the Italian DTC treatment model. These characteristics make it clear how fragile Italian DTCs are at this moment. They are still in an early stage of development. All the most applied and effective best practice procedures are dependent on a wide and dense network of relationships, formal and informal, which cross the therapeutic environment and interconnect TC members with all other stakeholders.

Resident interactions when affirming and correcting peers in a therapeutic community for women

Purpose While recent years have seen a number of studies of social networks in therapeutic communities (TCs) and other residential settings, these have primarily focused on male residents. This paper aims to conduct a longitudinal social network analysis of interpersonal interactions in a TC for women. Design/methodology/approach The data consists of a longitudinal directed social network of instances of feedback between 56 residents of a 16 bed TC for women over a period of 611 days. Mean age of the participants was 33.1 years, mean length of stay was 133.9 days and 91% of the participants were female. Feedback consisted of written affirmations for prosocial behavior and written corrections for contravening TC norms. Data was analyzed using a latent factor longitudinal social network model. Findings Residents react to peer intervention in complex ways. Residents reciprocated affirmations (B = 0.14, 95% confidence interval = 0.10, 0.18) and corrections (B = 0.20, 95% CI = 0.13, 0.25). Controlling for reciprocity, participants who received affirmations were more likely to affirm and correct peers (B = 0.10, 95% CI = 0.06, 0.15; B = 0.17, 95% CI = 0.10, 0.23), suggesting that the encouragement offered by affirmations leads to increased activity. Homophily by admission time occurred in both affirmations and corrections (B = 0.23, 95% CI = 0.10, 0.37; B = 0.51, 95% CI = 0.29, 0.74). Originality/value While affirmations and corrections serve as vehicles for behavioral reinforcement and social learning, they also allow residents to interact in ways that strengthen social bonds.

Prison Misconduct and the Use of Alternative Resolutions by Correctional Officers in Therapeutic Communities and Other Custody Units

This mixed methods study uses official records and interviews with inmates and staff to compare misconduct in therapeutic communities (TC’s) and the use of alternative resolutions (in lieu of formal charges by correctional officers) to other prison units. Prisoner misconduct has been studied using individual self-reports or aggregate prison rates, but unit level differences between TC’s and other prison wings are often overlooked. Restorative justice and diversion approaches are much studied in the community corrections literature but correctional officer use of alternatives to charging, such as mediation, is not well understood. The study examines differences in prisoner behavior by unit function by comparing misconduct over a 24 month period in therapeutic communities to general population, worker, protective custody, mental health, and high risk units. Study findings show lower misconduct in TC’s, including more serious misconduct such as fights. Furthermore, a significant proportion of overall charges were diverted into alternative resolution (AR)s, particularly within therapeutic communities. Interviewees reported a different approach taken in the TC toward discipline with a greater use of interaction, informal warnings, and application of AR, as opposed to formal charges. Future research is recommended using qualitative research strategies to appraise the alternative resolution decision process and prisoner-staff perceptions of discipline.

Therapeutic community work with people who have sexually offended: responding to developments in research and practice

Purpose This paper aims to review the clinical approach adopted in prison-based therapeutic communities (TCs) for working with residents who have committed sexual offences. It reviews recent research and practice developments and explores the implications for TCs. Design/methodology/approach This paper describes a “think tank” review process which explores and reviews practice. This paper discusses the current approach adopted by TCs when working with those who have sexually offended and explores changes in clinical approach which could be considered in the light of current developments. Findings This paper explores the implications for TCs of the recent research and wider practice developments in interventions for those who have sexually offended. Practical implications This paper presents clinical options for working with those who deny their offence and undertaking victim empathy and offence disclosure work. It makes recommendations regarding staff training and support. It also discusses the strengths of the TC approach and how these can be built upon. Social implications This paper makes recommendations concerning how practice could be improved which promotes safety and public protection and enhances resident well-being. Originality/value There has been no recent review of TC clinical practice for working with those who have sexually offended.

Difference in Response to Feedback and Gender in Three Therapeutic Community Units

Therapeutic communities (TCs) for substance abuse incorporate a system of peer feedback through written affirmations and corrections. Previous research has found that TC residents show a response to affirmations that is detectable for roughly 8 weeks, with response to corrections being of shorter duration and weaker overall. It is not clear whether and to what extent response to feedback in TCs varies between men and women. Previous research in other settings suggests that women should be more responsive to feedback than men. In order to test this hypothesis we draw on a large dataset of affirmations and corrections sent and received in three 80 bed TC units, two of which house men and one of which houses women. The analysis uses a multilevel negative binomial model, treating affirmations and corrections that TC residents receive as predictors of affirmations that they send over a 9 week period (week 0, the week during which affirmations and corrections are actually sent, and eight subsequent weeks). The model controls for gender, age, race, unit and scores on the Level of Service Inventory-Revised (LSI-R). The relationship between affirmations received and those sent is stronger for women during the initial week and on lags 1-2 and 5-8. The relationship between corrections received and affirmations sent is stronger for women on lags 2 and 8. Graphs suggest that response to affirmations falls off in an exponential curve, while that to corrections appears to include a periodic element. These results indicate that both men and women respond to feedback, but that the strength of the women's response is somewhat greater. These results suggest that any difference in suitability by gender to the feedback approach that characterizes TCs may favor women.

Working Paper Series: Therapeutic Communities in Brazil

Spread across Brazil and attaining an unparalleled political force, therapeutic communities are as inescapable in the debate on drug policy as they are complex to define. Although they are not a Brazilian creation, they have been operating in that country for decades, and their dissemination intensified in the 1990s. In 2011, they were officially incorporated into Brazil's Psychosocial Care Network (Rede de Atenção Psicossocial, or RAPS). Since then, therapeutic communities have been at the center of public debates about their regulation; about how they should—or even if they should—be a part of the healthcare system; about the level of supervision to which they should be submitted; about their sources of funding, particularly whether or not they should have access to public funding; and, most importantly, about the quality of the services they offer and the many reports of rights violation that have been made public. However, a well-informed public debate can only flourish if the available information is based on sound evidence. The SSRC’s Drugs, Security and Democracy Program is concerned with the policy relevance of the research projects it supports, and the debate around therapeutic communities in Brazil points to a clear need for impartial research that addresses different cross-cutting aspects of this topic in its various dimensions: legal, regulatory, health, and observance of human rights, among others. It is in this context that we publish this working paper series on therapeutic communities in Brazil. The eight articles that compose this series offer a multidisciplinary view of the topic, expanding and deepening the existing literature and offering powerful contributions to a substantive analysis of therapeutic communities as instruments of public policy. Although they can be read separately, it is as a whole that the strength of the eight articles that make up this series becomes more evident. Even though they offer different perspectives, they are complementary works in—and already essential for—delineating and understanding the phenomenon of therapeutic communities in Brazil.