The concept of a continuum for drug dependence implies that there is also a continuum of intervention strategies and treatment

Treatment options for drug and alcohol problems include Alcoholics Anonymous (AA) (Timko, Moos, Finney & Lesar, 2000; Weiss et al., 2000), and therapeutic communities (TCs) (Hall, Chen & Evans, 1995; De Leon, 1994; Nielsen & Scarpitti, 1997). Given the lack of consensus on the etiology of drug and alcohol problems (Craig, 1995), proponents of AA, and TCs tend to highlight the benefits of adopting their particular treatment intervention. However, a review of drug and alcohol literature indicates that although these two treatment interventions differ somewhat in their perspectives on drug addiction and their approach to alcohol and drug problems (Inaba & Cohen, 2000), they not only share similarities but are often used in conjunction with each other (e.g., Minnasota Model) (Winters et al., 2000; McKay et al., 1998).

The disease model of drug addiction …“acknowledges biological predisposition, pharmacological reinforcement of behaviour, accumulating organic damage, entrenched cognitive patterns, [and] family and developmental influences” (Jurd, 1996, pp. 5-6). The disease model assumes that addiction to alcohol and drugs, especially narcotics (Drummond, 1991), is caused by a physical defect, the problem is within the person rather then the drug (Clarke & Saunders, 19 ). Although AA is based on the disease model of addiction (Jurd, 1996) they do not “take any particular medical point of view (AA, 1976, p. xx), and are fundamentally spiritual, as opposed to religious, programs (Gaudry, 1994; Miller & Kurtz, 1994). Alcoholics Anonymous (AA) and similar groups (NA) are referred to as 12-Step programs because there are twelve defined steps in the program for recovery (Yalisove, 1998), and the focus of treatment is holistic in that it incorporates the physical, mental and spiritual aspects of the person (Goold, 2001).

The treatment intervention advocates abstinence, (physical), adherence to the 12-Steps, the 12-Traditions and other collective wisdom (mental), and the belief in a higher power and support from the sponsor/group (spiritual) (Goold, 2001). The 12-Steps incorporates important cognitive (Steps 1, 2, 3, 6,and 11), behavioural (Steps 4, 5, 8, 9, 10, and 12) (McCullough, 1995) and social (fellowship) (Miller & Kurtz, 1994) components founded on reinforcement, social learning, and reference group theory (Wallace, 1993). Individual character defects are viewed as the primary cause of using drugs and failure in life (Gaudry, 1994), and a fundamental premise of this approach is that the disease is progressive and controlled use of alcohol (or other drugs) is not possible (Watson, 1991). Twelve step programs are free, usually voluntary (Rivers, 1994), peer based, and employ confrontational approaches (Yalisove, 1998) within a group format (Monras & Gual, 2000). The only requirement for membership is a desire to stop the addiction (Rivers, 1994).

Gaudry (1994) posits that the recovery program helps to build self-concept through a process that engages addicts at their level of addiction, breaks down their isolation, guilt, and pain, and shows them they are not alone. Meetings are conducted by reformed addicts, and provide a forum in which members acquire new skills to maintain abstinence and enhance their quality of life (Gaudry, 1994). The telling of life histories (a narrative approach) has been the cornerstone of AA practices (Major, 2000), and the individual may, through attending meetings, develop a sense of acceptance, social affinity, and an opportunity for re-socialisation (Pisani, Fawcett, Clark & McGuire, 1993).

In addition to providing a sense of belonging, AA programs are not time-framed (Weiss et al., 2000) but focus on “one day at a time” (Wallace, 1993), and stress the importance of a lifelong commitment (McCrady, Epstein & Hirsch, 1996) towards maintaining abstinence and dealing with all of life’s problems (Snow, Prochaska & Rossi, 1994). Although AA programs recommend daily attendance for the first 90 days (McCrady, Epstein & Hirsch, 1996) it has been suggested that it is the extent of participation in the program, as opposed to attendance at meetings, that is associated with more positive outcomes (Montgomery, Miller & Tonigan, 1995; Fiorentine, 1999).

While the majority of AA and similar (NA) programs are conducted on an outpatient basis (Inaba & Cohen, 2000), alcoholic recovery homes such as Hazelden, and Synanon, the forerunner of American TCs, all grew out of the practices and philosophy of AA (Dodd, 1997). Although recovery homes have remained in the culture of AA, TCs have developed their own distinct culture of values, language, rituals, and traditions (Bassin, 1984, cited in Dodd, 1997).

The social model (White, 1991; Dodd, 1997) provides the TC with a consistent framework for environmentally focused recovery that employs cognitive, and behavioural training methods and ...

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The social model (White, 1991; Dodd, 1997) provides the TC with a consistent framework for environmentally focused recovery that employs cognitive, and behavioural training methods and techniques founded on reinforcement, social learning (Wexler, Falkin & Lipton, 1990; De Leon, 1991) and, given that the peer encounter is the cornerstone of group processes in the TC (Nielsen & Scarpitti, 1997), self-control theory. In addition there is an unusual mix of street idiom and language borrowed from various psychotherapeutic schools including psychoanalysis, gestalt therapy, and existential psychotherapy (De Leon, 1991).

The TC views drug abuse as over-determined behaviour (De Leon, 1991) and does not perceive drug abuse as being the individual’s main disorder. Rather, drug abuse is viewed as a symptom of deviant behaviour, reflecting impeded personality development or chronic deficits in social, educational, and economic skills (De Leon, 1994). The primary goal of the TC is to foster personal growth (Butt, 1990) through a process of global change that includes abstinence from drug use, elimination of antisocial behaviour, the expression of prosocial attitudes and behaviours, the acquisition of social and living skills, and the development of employability, (Butt, 1990; Nielsen & Scarpitti, 1997; Mattick & Hall, 1993; De Leon, 1994).

Staff members working in a TC consist of either lay counselors (ex-addicts) (White, 1991), a range of professionals that include social workers, psychologists, and psychiatrists (Cancrini, De Gregorio & Cardella, 1994) or a combination of both (Butt, 1990). The relatively few staff members monitor and evaluate resident’s status, supervise groups, assign and supervise job functions, and oversee house operations (De Leon, 1994). Residents are responsible for their daily living requirements, maintaining their living quarters, and assisting in the general upkeep of the TC (Nielsen & Scarpitti, 1997).

Contemporary TCs usually adopt a non-medical approach (Hall, Chen & Evans, 1995), offer programs ranging from 3mths to 18mths duration (Ghodse, 1995), operate on a 24 hour live-in basis, and conduct random urine testing (Charuvastra, Rehmar, Paredes & MCBride, 1989). TCs provide the individual with a structured drug-free environment and clear boundaries (Nielsen & Scarpitti, 1997; Butt, 1990) so as to encourage individual responsibility for the self and group responsibility for the community (Blake, Millard & Roberts, 1984). In addition, there is a defined system of rewards for good behaviour (e.g., privileges) and punishments (e.g., sanctions and penalties) for not adhering to community guidelines (Ghodse, 1995; De Leon, 1994; Butt, 1990). Although the TC fosters a trial and error learning process in which the individual can fail safely (De Leon, 1991b), any infringement of the cardinal rules (no violence, no stealing, no sex, no drugs) often results in immediate discharge (Butt, 1990; Glaser, 1981).

Rehabilitation and recovery unfolds as a developmental process that occurs in a social learning setting, and often involves stages of sequenced incremental learning as the individual progresses through various phases (e.g., orientation, primary treatment, graduation, re-entry, and aftercare) in the program (De Leon, 1994). Although individual counseling is usually available to assist residents in resolving underlying or core issues that led to their drug abuse, there is usually an emphasis on group methods (Nielsen & Scarpitti, 1997). De Leon (1994) suggests that the most important mechanism for change is the community of peers who confront their fellow resident/s (in encounter groups) when old values and behaviours are displayed, provide positive and negative reinforcements to elicit appropriate behaviour, and serve as role models.

The principal goal for the individual is re-entry into society (Hall, Chen & Evans, 1995) however “relapse is the rule across all treatment approaches” (De Leon, 1994, p. 1225) and usually occurs within the first 90 days (Butt, 1992). In an effort to reduce relapse individuals are, depending on their level of progress, allowed day, overnight, and weekend leave so as to experience and overcome high-risk situations, and reintegrate back into mainstream society (Butt, 1992). In addition, the majority of TCs provide additional support through aftercare programs that include re-entry or halfway houses (De Leon, 1991b), and emphasise the use of self-help groups such as AA, and NA (Troyer, et al.; 1995; Butt, 1990). Wexler’s (1995) suggestion that AA is primarily a support model whereas the TC is a self-help intervention model warrants some thought given that both treatment interventions adopt similar practices.

TCs and AA both advocate abstinence, are peer based programs that employ confrontational techniques within a group format, and view the individual as being responsible for their own recovery. In addition, TCs and AA adopt similar theoretical approaches, provide a drug-free environment for social interaction, and emphasise learning new skills. While it would also appear that the majority of individuals who access AA and TCs are experiencing severe drug (Condelli & Hubbard, 1994; Weiss et al., 2000), and alcohol problems (Tonigan, Toscova & Miller, 1996), TCs appear to acknowledge the uniqueness of each individual.

In AA, all members follow the same regime whereas individual differences are recognized in TCs through specific treatment plans that change the emphasis, not the course, of their experience in the TC (De Leon, 1994). TCs also distinguish individuals along dimensions of psychological dysfunction and social deficits rather than according to drug-use (e.g., alcoholics versus social drinkers) patterns (De Leon, 1994; Jarvis, Tebbutt & Mattick, 1995). In contrast to AA, TCs usually have exclusion criteria (e.g., psychopathological disorders) so as to ensure a safe and predictable environment for residents, especially in relation to female residents. However, unlike AA, the majority of TCs in Australia are not a viable alternative for some women who have children. Although the research from studies indicates positive outcomes with AA (Tonigan, Toscova & Miller, 1996; Timko et al., 2000; Mann, et al., 1991), and TCs (Page & Mitchell, 1988; Simpson & Sells, 1990, cited in Platt, Husband & Taube, 1991), both treatment interventions are difficult to evaluate due to significant methodological constraints, and the influence of extraneous variables.

AA has been criticised for its lack of client monitoring and treatment evaluation, and the use of non-professionals helping people who may have severe psychological disorders (Major, 2000). In contrast, TCs have been accused of providing a pseudo-environment where residents risk becoming dependent on the TC itself, and delay the chance to implement what they have learned (Butt, 1990). In addition to the limitations associated with self-report data, TCs experience high attrition rates (De Leon & Schwartz, 1984) and encounter difficulties in locating ex-residents during follow-up studies (Charuvastra, et al., 1989), whereas controlled trials on the effectiveness of AA are difficult as AA insists on anonymity, and membership is voluntary so no one can be turned away (White, 1994).

It is evident from the literature discussed throughout this paper that the boundaries between AA, and TCs programs are somewhat blurred. While there were notable similarities and differences between AA and TCs, the AA program could be considered somewhat disempowering as members view themselves as being in a constant state of recovery that requires life-long vigilance (Troyer et al., 1995). Fortunately, AA is widespread, easily accessed, and cost nothing to attend (Saunders, 1998). Although the evidence to support the effectiveness of either approach appears somewhat tentative, the diffusion (e.g., settings, countries) of AA (Makela, 1991), and TCs (Cancrini, Gregorio & Cardella, 1994) suggests that these two interventions are considered to be, at least for some individuals, viable options for the treatment of alcohol and drug abuse.

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