Speech by Phaedon Kaletorakis, Assistant Director of KETHEA, on behalf of the World Federation of Therapeutic Communities, at the intersessional meeting of the the 63rd CND, in October 19, 2020, in Vienna.
Drugs is not the problem, addiction is. I believe that this small phrase encompasses all basic principles of treatment. It implies that we cannot demonize substances – there are only matter, after all – but at the same time, puts an emphasis on addiction as a human behavior. Embracing this statement also means that we understand addiction not simply as an illness but as a multifactorial health phenomenon that requires a complex and comprehensive approach.
Accordingly, the United Nations General Assembly Special Session in 2016 recognized “drug dependence as a complex, multifactorial health disorder characterized by a chronic and relapsing nature with social causes and consequences that can be prevented and treated”.
The therapeutic community (TC) is a well-established and evidence-based treatment modality that provides services either augmenting high quality medication-assisted treatment or as a monotherapy .
Most contemporary TCs attract a population with mainly poor prognostic indicators for addiction treatment: polydrug use, psychiatric comorbidity, poor work history, significant criminality etc. [2,3].
Critical evidence from large-scale effectiveness studies, randomized-controlled trials and meta-analyses support TCs as effective, cost-saving interventions [3,5,6]. The patient outcomes measured, usually include sustained abstinence, reduced drug use, employment and criminal behavior .
Organizations like the therapeutic communities espouse a bio-psycho-social approach to the treatment of addiction.
The biological aspect is apparent because we do know that addiction affects the brain and its functioning, whereas addiction as a coping mechanism for past traumas manifests the psychological dimension. Also, we should take into consideration that addiction became a massive social phenomenon after (and because of) the industrial revolution. That is why we, in the field of treatment, understand addiction as a health issue of mainly a bio-psycho-social nature.
Today, we face a new reality. The coronavirus pandemic has brought an economic and social crisis of considerable magnitude. How we, in treatment, react to this, is of paramount importance.
Ten years ago, when the recession hit Greece, we saw a serious increase in substance use. More men using alcohol as a refuge, more women taking benzodiazepines. At the same time, funding for health and social services was reduced dramatically.
For all these reasons, I strongly believe that this is the time to emphasize the political aspect of the issue. Let me clarify this. Obviously, I am not talking about partisan politics but I am using the word in its Aristotelian broader sense. We, both decision makers and treatment professionals, are part of the polis-city, we are concerned citizens. We should face the future and the challenges that lie ahead by drawing from our rich experience, from our values and tradition, from our past.
Along these lines, I would like to offer the five following observations concerning the place of treatment services and more specifically the TCs, in the health spectrum.
- We must acquire a stronger voice as treatment organizations and TCs in particular. Our services, together with prevention and harm reduction, should be an integral part of the continuum of care in any national health system. In some countries the reality is that TCs are marginalized and undervalued. This needs to change. Decision makers need to be persuaded of the necessity for adequate services thus providing the required funding.
- We need to advocate for services aimed towards the most vulnerable groups: women, children, the homeless, people with HIV, Hepatitis C, co-occurring disorders, offenders and others. Women, for example, make up globally one third of people who abuse drugs but just one fifth of those who are in treatment. Unfortunately, during a recession the first services to have serious cutbacks are the ones we have just mentioned.
- Recession also brings unemployment. With higher unemployment, social reintegration becomes very difficult to achieve. Treatment organizations therefore, should diligently and methodically redesign their re-entry programs to adapt to this new reality. At the same time, we should seek the passing of laws that make it easier for people who complete treatment to reintegrate.
- Experts say that the coronavirus pandemic is closely related to the destruction of the environment. Environmental awareness should become an essential part of the treatment process. Clients and staff need to be educated and trained in related matters.
- These are times that we need each other even more. The development of efficient networks on a national and an international level is a priority. Treatment programs and organizations reaching out to others and seeking a unified voice, is the way to go.
In Greek the word “treatment” is “therapeia”. It derives from the word “therapon” (therapist), which is first recorded in Homer’s Iliad. It originally signified the servant who helps a warrior put on his armor before the battle. Health providers, and more specifically addiction professionals, are exactly this: therapists, servants who serve people in their need. They equip vulnerable individuals so that they can go fight their personal battles. Few months after UNGASS 2016, the World Federation of Therapeutic Communities (WFTC) produced the Declaration of Mallorca which concludes with the following words: “This declaration reaffirms the commitment of the Therapeutic Community movement to serve addicted populations and their social networks all over the world by restoring their hope, dignity and personal well-being.”
- Avery J, Kast K. The Opioid Epidemic and the Therapeutic Community Model, An Essential Guide, Springer Nature Switzerland AG, 2019
- DeLeon G. Therapeutic Communities. In: Galanter M, Kleber HD, Brady KT, editors. The American psychiatric publishing textbook of substance abuse treatment. 5th ed; 2015a.
- DeLeon G. Is the Therapeutic Community an evidenced based treatment? What the evidence says. Int J Therap Commun. 2010;31(2):104–28.
- Maughan D, Lillywhite R, Pearce S, Pillinger T, Weich S. Evaluating sustainability:a retrospective cohort analysis of the Oxfordshire therapeutic community. BMC Psychiatry. 2016;16(1):285.
- Sacks S. Overview of therapeutic community outcome research. In: Ries RK, Miller SC, Saitz R, Fiellin DA, editors. American Society of Addiction Medicine The ASAM principles of addiction medicine. 5th ed. Philadelphia: Wolters Kluwer Health and Lippincott Williams & Wilkins; 2014.
- Vanderplasschen W, Colpaert K, Autrique M, Rapp RC, Pearce S, Broekaert E, Vandevelde S. Therapeutic communities for addictions: a review of their effectiveness from a recovery-oriented perspective. Sci World J. 2013;2013:427817.