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Center for Substance Abuse Treatment. Treatment of Adolescents with Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 32.)

Cover of Treatment of Adolescents with Substance Use Disorders

Treatment of Adolescents with Substance Use Disorders.

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Chapter 5—Therapeutic Communities

The therapeutic community (TC) is an intensive and comprehensive treatment model developed for use with adults that has been modified successfully to treat adolescents with substance use disorders. TCs for the treatment of addiction originated in 1958, a time when other systems of therapy, such as psychiatry and general medicine, were not successful in treating alcohol or substance use disorders. The first TC for substance users (Synanon) was founded in California by Chuck Dederich, one of the earliest members of Alcoholics Anonymous (AA), who wanted to provide a controlled (substance-free) environment in which alcohol and substance users could rebuild their lives, using the principles of AA along with a social learning model (De Leon, 1995a).

The core goal of TCs has always been to promote a more holistic lifestyle and to identify areas for change such as negative personal behaviors--social, psychological, and emotional--that can lead to substance use. Residents make these changes by learning from fellow residents, staff members, and other figures of authority. In the earliest TCs, punishments, contracts, and extreme peer pressure were commonly used. Partly because of these methods, TCs had difficulty winning acceptance by professional communities. They are now an accepted modality in the mainstream treatment community. The use of punishments, contracts, and similar tools have been greatly modified, although peer pressure has remained an integral and important therapeutic technique.

Originally, the large majority of residents served by TCs were male heroin addicts who entered 18- to 24-month residential programs. By the mid-1970s, a more diverse clientele was entering treatment; 45 percent used heroin alone or in combination with other substances, and most were primarily involved with a range of substances other than heroin, such as amphetamines, marijuana, PCP, sedatives, and hallucinogens. By the 1980s, the large majority of those entering treatment in TCs had primarily crack or cocaine problems. The percentage of women entering treatment grew, and they presented with different problems, including extremely dysfunctional lives and more psychopathology. Although several adolescent TCs have been in operation since the late 1960s, increasing numbers of younger people sought treatment during the 1980s, and many previously all-adult communities began admitting adolescents. With the inclusion of youths in these adult TCs, education and family services were added as important program components.

The TC model has been modified over time to include a variety of additional services not provided in the early years, including various types of medical and mental health services, family therapy and education, and educational and vocational services. In the beginning, nearly all staff members were paraprofessionals recovering from addiction; over the years, increasing numbers and types of professionally trained specialists have been employed by TCs and are now serving in staff or consultant positions.

The Generic TC Model

As a social-psychological form of treatment for addictions and related problems, the TC has been typically used in the United States to treat youth with the severest problems and for whom long-term care is indicated. TCs have two unique characteristics:

  • The use of the community itself as therapist and teacher in the treatment process
  • A highly structured, well-defined, and continuous process of self-reliant program operation

The community includes the social environment, peers, and staff role models. Treatment is guided by the substance use disorder, the person, recovery, and right living (De Leon 1995a).

Right living emphasizes living in the present, with explicit values that guide individuals in relating to themselves, peers, significant others, and the larger society. Recovery is seen as changing negative patterns of behavior, thinking, and feeling that predispose one to substance use and developing a responsible substance-free lifestyle. It is a developmental process in which residents develop the motivation and know-how to change their behavior through self-help, mutual self-help, and social learning.

The theoretical framework for the TC model considers substance use a symptom of much broader problems and, in a residential setting, uses a holistic treatment approach that has an impact on every aspect of a resident's life. Residents are distinguished along dimensions of psychological dysfunction and social deficits. The community provides habilitation, in which some TC residents develop socially productive lifestyles for the first time in their lives, and rehabilitation, in which other residents are helped to return to a previously known and practiced or rejected healthy lifestyle (De Leon, 1994). A primary distinction between the TC approach and 12-Step-based programs is the belief that the individual is responsible both for his addiction and for his recovery. Where AA says "let go, let God," TCs take the view that "you got yourself here, now you have to get yourself out with the help of others."

Traditionally in the TC, job functions, chores, and other facility management responsibilities that help maintain the daily operations of the TC have been used as a vehicle for teaching self-development. Remaining physically separated from external influences strengthens the sense of community that is integral to the residential setting. Activities are performed collectively, except for individual counseling. Peers are role models, and staff members are rational authorities, facilitators, and guides in the self-help method. The day is highly structured, with time allocated for chores and other responsibilities, group activities, seminars, meals, and formal and informal interaction with peers and staff members. The use of the community as therapist and teacher results in multiple interventions that occur in all these activities.

Treatment is ordinarily provided within a 24-hour, 7-days-per-week highly structured plan of activities and responsibilities. Although recommended treatment tenures have generally shortened in recent years, averaging around 1 year, they may last as long as 18 months. The full-time approach is part of the ecological point of view held by proponents and leaders of TCs. The program is conducted in three stages: induction, primary treatment, and preparation for separation from the TC (De Leon, 1994).

Like many other substance use disorder treatment providers in today's health care market, TC personnel are committed to providing services to residents in shorter periods of time and with decreased resources than was the case in previous years. Modifications of the traditional residential model and its adaptation for special populations and settings are redefining the TC modality within mainstream and mental health services. Two new strategies have recently been suggested: focusing goals on moving the resident to the next stage of recovery in another, less expensive setting, or expanding aftercare opportunities in residential and day treatment programs following TC treatment (De Leon 1995a, 1995b; Rosenthal et al., 1971).

Adolescents in TCs

Jainchill and others have pointed out that only recently has cross-site information describing adolescents who enter TCs been compiled (Jainchill, 1997). One exception was the Drug Abuse Reporting Program (DARP), which in the 1960s and 1970s found that almost one-third of the TC sample was younger than 20 years old. (DARP was the nation's first comprehensive multimodality study of the treatment industry.) Those teenage TC residents typically were white males who used opioids (Rush, 1979). Data are sparse after the 1970s. However, new data reveal that adolescents make up 20 to 25 percent of the residents in TCs. Some 80,000 clients were admitted to TCs in 1994 (De Leon, 1995b).

Resident Characteristics

Adolescents who enter TCs tend to have serious substance use and behavioral problems that render them dysfunctional in many arenas (Jainchill, 1997). Common problems are truancy, conduct disorders, poor school performance, attention deficit/hyperactivity disorder (AD/HD), learning disabilities, and problems relating to authority figures. In terms of substance use history, adolescents entering TCs have begun substance use at an earlier age and have greater involvement with alcohol and marijuana and less use of opiates compared with adults.

A majority of youths in TCs have been referred by the juvenile justice system, family court, or child welfare (social service) systems and reflect an early involvement with illegal activities and family dysfunction. Conduct disorders and juvenile delinquency are common. In fact, some TCs are operated by criminal justice institutions, such as correctional agencies, and may be structured as minimum-security correctional facilities.

Less frequently, adolescents enter the TC under parental pressure. Thus, extrinsic pressures are usually required to coerce the adolescent into treatment and to keep her there. It is not uncommon for such residents to have little motivation to change their behavior.

Most adolescent residents are males mandated by the court, and problems of social deviance are commonplace. Because adolescent females commit fewer crimes and less violent ones than do adolescent males (Jainchill et al., 1995), they are not often mandated to a TC, although they may be brought to treatment by a family court. However, even those adolescent females with the same range and type of problems as the males generally do not enter TCs. One of the questions facing the TC movement is how to create and conduct effective outreach for adolescent females who need treatment. Very often, when females do enter TCs, their problems are found to be more severe than the problems of most of the males. When females are enrolled in the TC, sleeping quarters are separate but activities are very often coed (Jainchill et al., 1995).

Both adults and adolescents in TCs share many problems. There is little difference between the social histories of adult and adolescent users in residential treatment concerning onset and pattern of substance use, academic performance, and juvenile delinquency (De Leon, 1988).

TCs With Adolescents

A core feature of TC treatment for adults and adolescents alike is that the community serves as the primary therapist--treatment is a community process, and it is not possible to identify a single individual as therapist. Although adolescents often have a primary counselor with whom they work individually, everyone in the community, including the adolescents themselves, has responsibility as a therapist and teacher. Peer-group meetings led by an adolescent with a staff facilitator are common.

The community's role is critical to the client's habilitation and rehabilitation. For the adolescent, the community may be even more crucial than for adults because the TC functions as the family. This is a significant function because many youths in TCs come from dysfunctional families. Being a member of the TC community gives them an opportunity to experience and learn how to have and maintain positive relationships with authorities, parents, siblings, and peers. Nearly all activities, even housekeeping responsibilities, are considered part of the therapeutic process. It is precisely because adolescent residents usually come from environments without structure, routine, rules, or regulations that the TC is ideally suited to providing their treatment.

Modifications that are generally made in the TC model for treatment of adolescents are summarized as follows:

  • The duration of stay is shorter than for adults.
  • Treatment stages reflect progress along behavioral, emotional, and developmental dimensions.
  • Adolescent programs are generally less confrontational than adult programs.
  • Adolescents have less say in the management of the program.
  • Staff members provide more supervision and evaluation than they do in adult programs.
  • Neurological impairments, particularly learning disabilities and related disorders (e.g., AD/HD), are assessed.
  • There is less emphasis on work and more emphasis on education, including actual schoolwork, in the adolescent program.
  • Family involvement is enhanced and ideally should be staged, beginning with orientation and education, then moving to support groups, therapy groups, and therapy with the adolescent. When parental support is nonexistent, probation officers, social workers, or other supportive adults in the youth's life can participate in therapy.

Additional modifications are made depending on the specific needs of the program's referral and funding sources (Rockholz, 1989). For example, some programs primarily serve protective services cases (e.g., abuse and neglect, homelessness) involving adolescents who often present with psychiatric needs that require medication. Others serve juvenile and criminal justice system-involved youths with behavioral disorders, who require anger management programming and who respond better to more traditional confrontation techniques. Still others operate college preparatory TCs, without the use of psychotropic medications, for emotionally troubled, upper-middle class youths.

Duration of Stay

In the past, TCs for adolescents were entirely residential programs lasting 18 months to 2 years--the time required for behavior change to be internalized and practiced by the adolescent. The conservative funding policies that typify the 1990s have introduced complex issues for residential TCs because success in treatment is correlated positively with extended stay in the program. As with so many other issues in substance use disorder treatment today, final decisions often have to be based more on financial considerations than on therapeutic need, with the result that most programs can plan only for a course of treatment that lasts 6 to 12 months. A few programs are attempting to provide TC treatment in 6 months; this is a radical move. Clinical wisdom suggests that the ideal duration of treatment for adolescents in a TC is 12 to 18 months and that adolescents with very deep and complicated disorders cannot be treated effectively in 28 days. However, no research is available to compare treatment success in 28-day programs with treatment in the longer stay programs.

Staffing

Originally, only persons in recovery staffed TCs, and TC directors and staff were opposed to therapy by psychologists, psychiatrists, and other mental health personnel such as social workers or family counselors. TCs are now integrating the services of professionals with training in some area of mental health, and there is recognition that individual counseling can complement the group approach, which was the mainstay of treatment during the first two decades of TCs.

TC staffs today are a mixture of nondegreed frontline counselors and degreed professionals. The counselors who do not have degrees typically facilitate the daily TC activities and serve as role models for successful recovery; the degreed staff includes vocational counselors, nurses, psychologists, social workers, and substance abuse counselors.

Having an on-site nursing staff is important to monitor medications, provide health education, and provide cross-training for the counselors, particularly regarding the symptomatology of addiction. Teachers in a TC program for adolescents must understand substance use disorders among youths from disadvantaged families with severe dysfunction. Cross-training for the teachers is also important. It is essential that the counselor meet at least weekly with the teacher(s) to integrate schooling into the program. Psychiatrists are often involved because of the common presence of disorders such as depression or AD/HD. Pharmacological agents for coexisting disorders are now permitted and are used widely by some TCs serving adolescents with coexisting mental disorders.

Depending on the size and staffing of the TC, there will be some combination of administrative, legal, dietary, and maintenance staff. The people in these categories are often considered integral to the clinical process. For example, office personnel may actually have some clinical input in terms of hands-on management of a resident who has a job function under their supervision. It is essential that all employees who have any direct or indirect dealings with residents receive training that gives them a thorough understanding of the TC concept and its bearing on their specific duties.

Protocol

Most programs are designed so residents can progress through phases as they advance through treatment. Tied to the phases are increased responsibilities and privileges. One cannot advance to the next higher level until he demonstrates responsibility, self-awareness, and consideration for others (De Leon, 1995a). By moving through these structured phases, the adolescent acquires and benefits from psychological and social learning before proceeding to the next stage. Each stage prepares the resident for the next. After becoming a responsible member of the treatment community, the adolescent can move on to the outside community. In adult TCs, residents advance through developmental stages to a level of authority in which they become responsible for the TC's operation. However, this is not appropriate for adolescents, for whom the staff plays the role of effective parents.

Creating a Safe Environment

Part of the ecological approach to treatment in the TC is the creation of a safe and nurturing environment, within which adolescents can begin to experience healthy living. It is important for the staff of the TC to understand what type of home, neighborhood, and social environment from which each adolescent comes. Many adolescents enrolled in the TC come from unsafe physical and psychological environments; the characteristics of the home and neighborhood do not facilitate healthy living, and many risk factors may be environmental. For example, many of these adolescents are third-generation substance users who have grown up in an environment where substance use is an everyday activity. Often, physical or psychological violence accompanies the addictive practices, and children and adolescents may be physically and psychologically damaged.

Essential to creating a safe environment is the TC's strict adherence to "cardinal rules" that, at a minimum, prohibit substance use or possession, physical threats or violence, or sexual contact. It is also essential that the environment be psychologically safe by ensuring, for example, that adolescents are not verbally attacked and that they feel comfortable enough to disclose even the most sensitive of events (and associated feelings), such as sexual abuse.

Groups in the TC for Adolescents

Various types of counseling groups are provided in the TC. Groups constitute an important therapeutic technique, as they have since the earliest TCs were established. Typically, everyone attends at least one group session a day.

Today's TCs generally do not use the grueling encounter groups and all-night "marathons" of their earlier counterparts, but modified encounter groups still are common. Some programs have begun to move away from encounter groups and have included 12-Step work, as in the 12-Step model of treatment. Techniques such as confrontation, designed to help adolescents recognize and acknowledge their feelings and learn to accept personal and social responsibility, can be counterproductive by raising clients' defensiveness. Group meetings at advanced stages of the program are composed of peers, whereas other groups for adolescents are led by qualified counselors or therapists. Many of the TC programs for adolescents use a cognitive restructuring approach to change adolescents' thinking and to redirect the focus of their attention to healthier behavior.

There are various types of groups that deal with physical and sexual abuse, although it is very difficult to get adolescents to acknowledge that they have experienced abuse. Skill groups also exist in adolescent TCs to enhance existing skills or build new ones.

Education

Enabling residents to receive a good education and at least complete high school are critical goals for adolescent TCs. Comprehensive TCs provide their own schools, licensed as required, with full-time, salaried, or local educational agency-provided teachers. Others have a teacher who comes in part time to conduct classes. All teachers must be State-certified to provide special education or education in their specific subject area. Residents must receive a minimum of 5 hours of academic instruction per school day. It is critical that educational services be fully integrated into the TC program and that they be consistent with the TC process. Teaching staff should be active in the treatment planning process, and behavioral management programming should be integrated into the "house" procedures.

Because schooling replaces most of the work responsibilities common in adult TCs, the adolescent's workload is not as heavy as that of the adult. Each resident has assigned job responsibilities in the evening and on weekends, such as preparing dinner, washing dishes, mopping, dusting--the important tedium of sober life. After dinner, there is study time and a group meeting. Lights-out is monitored at a specific time, such as 10:30 p.m.

Recreation

Recreational activities are important for teenagers in TCs who need help in learning to enjoy themselves and others without using substances. These activities help overcome boredom, a key problem with adolescents. Physical activities, such as outdoor sports, are necessary but difficult to provide in winter, particularly in programs that are housed in a limited amount of space. Some TCs have incorporated relationships with local public facilities or programs such as Outward Bound.

Aftercare

During the first two decades of the TC, residents spent 18 to 24 months in treatment and were essentially considered to be "cured" and not in need of formal aftercare services. As the average length of stay decreased, however, it became necessary to return adolescents to their families or independent living situations with continuing treatment needs. Others required halfway houses, which were, and continue to be, scarce. In most cases today, adolescents are referred to outpatient programs, especially for continued family therapy. Some are served through alumni or other affiliated aftercare resources of TC agencies. Although Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are minimally included in many adolescent and adult TCs, most programs have experienced significant improvements in treatment outcomes when they introduce residents to AA/NA during the reentry phase of treatment and strongly encourage them to use these 12-Step programs as valuable and effective aftercare supports. Evaluative work documenting significant reductions in recidivism, substance use, and antisocial behavior through the use of dedicated TC residents in the community for aftercare is just beginning to emerge, primarily from researchers dealing with adult prison populations (Inciardi et al., 1997). Ideally, sophisticated satellite aftercare programs should be provided in the communities where the residents live. For adolescents, aftercare programs should include a family therapy component.

Involvement of the Adolescent's Family

In the early days of the adolescent TC, families were often viewed as the cause of the adolescent's problems and were kept away from the adolescent. Families were usually only involved with occasional parent support groups or Al-Anon and thus were kept away from their children. For cases in which the adolescent planned to return home, parents were usually brought in for a conference or two shortly before the adolescent left residence in the TC. In many cases, adolescents were older and tended to move out to independent living in the community near the TC program--often with little or no family counseling.

Today, TCs often provide comprehensive family services programs, including such components as family assessments, family counseling and therapy including multifamily groups, parent support groups, and family education programs. Some TCs have well-established parent groups that provide program fundraising and scholarship assistance initiatives. Regular visitation remains limited in most TCs to weekly or monthly open houses and special events such as graduations.

The issues of accessibility and limited family supports are challenging to TCs, especially when they are located away from families. Many families lack the transportation or interest to be involved in regular family programming. In some cases, adolescents have no living parents or have a parent who is incarcerated. In cases such as these, teleconferencing and family counseling with the individual are necessary alternatives. Some programs develop agreements with other service providers where the family resides. These programs can help with parenting skills training and can provide support and guidance on how to help the youth maintain his recovery. The TC tends to provide a surrogate extended family for residents, which can provide a corrective experience resulting in more positive self-identity. Ideally, staff members and the community as a whole provide effective reparenting through a balance of discipline without punishment or shaming, along with love and concern without enabling.

Related to this is the issue of rural programs versus urban programs that are located closer to the homes of TC residents. Proponents of city programs argue that it is unfair to take adolescents away from their families for the duration of treatment. On the other hand, if the family is really dysfunctional, it is better to keep adolescents away from their family. Locating the adolescent in a rural area away from the environment in which she was involved with substances and away from her peers in that environment may strengthen the adolescent's resistance upon return to that environment. There is disagreement on this matter, however; some authorities believe there is no value in moving the adolescent to a rural area. Others take a middle ground by placing the adolescent in a rural TC initially and then returning the youth to treatment in her original environment.

Special Issues of the Adolescent TC Resident

TC staff members must be prepared to deal with many special issues of adolescents that will come to the fore in the treatment process. Three are particularly common and important: self-image, guilt, and sexuality (De Leon, 1988; Jainchill, 1997).

Self-image

Adolescents are struggling to develop an identity, which is a critical and sometimes difficult task, even for those leading ordinary lives without the types of problems experienced by an adolescent in the TC. They often select images they want to assume, body postures, and an affected manner of speaking that may be inappropriate. Their images may be embedded in street culture and gang affiliation. Staff members can work with them and help them see how a healthy identity develops and is maintained; they are in a position to help the adolescent avoid the acquisition of a negative self-image that can be destructive. Once this stage of understanding has been reached, staff members can help adolescents develop self-monitoring methods to assess their own images as well as images of others and to suggest changes in behaviors, dress, speech, or even posture, when appropriate.

Guilt

Many experienced TC professionals view guilt as the fundamental feeling associated with self-defeating behavior, including substance use and acting out against others (such as by stealing). They frequently say to adolescents, "Guilt kills," which expresses their understanding that negative behavior produces guilt, which in turn, results in more negative behavior to escape guilty feelings. Adolescents can benefit from help with self-guilt (e.g., how their actions have hurt other people) and community guilt (e.g., breaking house rules or not confronting negative behavior and attitudes of other residents).

TC staff members regularly address guilt in encounter groups, seminars, counseling, and even in special guilt sessions, in which confession is the first step in counteracting the feeling of guilt. While it is necessary to disclose the act itself, the root issue in these sessions is the concealment of that act, which the adolescent must confess. Discussion of guilt is valuable for all adolescents, whether they are undergoing group, community, or individual therapy (DeLeon, 1995a). It is of critical importance that the residents understand the relationship between guilt and self-destructive behavior. Recognition and acceptance of the pain associated with guilt is the first step to an experiential basis for new social learning. Finally, it is hoped that the resident will understand that acknowledging past misdeeds can be a springboard for commitment to a changed future.

Sexuality

Sexuality, social behavior, and personal identity are interrelated in all human beings, but problems in these areas are intensified during adolescence. Staff members will encounter problems related to sexual feelings, sex roles, values, attitudes, and interpersonal relationships between the sexes. Some residents may be trying to cope with feelings related to sexual abuse. The adolescent must learn to manage strong sexual impulses. Sexual adjustment of adolescents with substance use disorders is complicated by other problems such as the lack of sex education at home or school or having poor role models. Altogether, there is a risk that the adolescent will develop distortions in attitude, values, and self-perceptions regarding sex.

TC professionals can best deal with these problems through management and rules (e.g., rules against sexual contact) and through providing sex education in seminars as well as dealing with sexual issues during encounter groups, one-on-one counseling, and special sessions that are focused on problem solving. Boys' and girls' living spaces should be separated. The longer term stay and increased contact make TCs a good environment for counseling and education on HIV infection, AIDS, and safe sex; the TC can make a real contribution to the young person's life by helping her understand and practice safe sex.

Research Studies

There is no consensus definition of successful treatment outcomes for adolescent TC programs. Some TCs believe they have been successful if, after treatment, the adolescent uses only marijuana. Others measure treatment success by reductions in the amount of substance use and in criminal and delinquent behavior. For some, the standard of abstinence from all substances and complete cessation of all delinquent behavior following treatment is the ultimate goal. Still others have looked at indicators such as improvements in the adolescent's self-esteem, quality of relationships with others, and improvement in academic performance and attendance (Rockholz, 1978).

Data on the TC approach to adolescent care come from recent reviews of the literature (e.g., Jainchill et al., 1995; Pompi, 1994) and current adolescent studies by Jainchill and associates at the Center for Therapeutic Community Research (CTCR) (Jainchill, in press). Other sources of information are earlier multimodality studies involving adolescents in TCs, funded by the National Institute on Drug Abuse (Hubbard et al., 1989) and large multiprogram studies of TC programs in Therapeutic Communities of America (De Leon, 1985).

Using data from these sources, it is possible to hypothesize that retention rates and post-treatment outcomes are similar to those among adults, with adolescents showing positive changes in the use of cocaine, opiates, and methamphetamine and reductions in criminal activity. The majority of adolescents admitted to TCs who drop out do so within the first 30 days. Dropout rates diminish after that time. Retention rates vary considerably among programs. The highest retention rates are found among adolescents who are legally mandated to treatment, probably because fulfilling the court requirement supports the adolescent while he undergoes compliance, which lays the groundwork for the retraining stages that occur in later therapy. Thus, a legal mandate can be a valuable tool in increasing adherence to and efficacy of treatment (De Leon, 1995b).

There has been a long-held clinical impression that younger clients are less motivated than adults to be in treatment, and this impression has recently been confirmed by empirical data from CTCR, although younger clients are likely to remain in treatment longer if they are highly motivated to be there. If motivation and readiness can be assessed at intake, treatment providers may be able to identify those youths who are at high risk for dropping out. Such information could guide the development of intervention strategies to enhance motivation and retention in treatment.

Outcome Studies

The relatively few studies that have reported on the effectiveness of long-term residential treatment indicate that residential treatment is generally more effective than outpatient modalities, that a client's length of stay in treatment is a critical factor, and that adolescents require a longer treatment tenure than adults (e.g., De Leon, 1985; Hubbard et al., 1985; Sells and Simpson, 1979). Among these studies the most consistent improvements were seen on measures of criminal involvement with marijuana, and there has been a notable lack of marijuana-specific treatment studies.

Jainchill and colleagues recently completed a 1-year posttreatment followup study of adolescents who were in residential therapeutic communities (Jainchill et al., in preparation). The majority (46 percent) indicated that marijuana was their primary drug of abuse. Followup interviews were completed on 485 adolescents of whom 31 percent graduated or completed the residential phase of treatment, 52 percent dropped out, and the remainder were terminated for a variety of other reasons. There were significant reductions in substance use, both in the percentage of adolescents reporting use of specific substances and in the extent or frequency of use. Those who completed treatment showed more positive outcomes than those who did not complete treatment. There were similar improvements obtained in the level of criminal activity. For both those who completed treatment and those who did not complete treatment, there were significant reductions in all areas of criminal activity (e.g., violent crimes, drug sales, property crimes); however, the reductions were greater for those who completed treatment. Continued research supported by the National Institute on Drug Abuse is investigating long-term outcomes (5 and 7 years after treatment) for those adolescents. The need for further studies is critical, particularly for those that address the issue of treatment duration and tenure in relation to outcome.

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