On 25 January 2016 Coolmine Therapeutic Community (CTC) published the results of a longitudinal outcomes study Pathways through treatment: a mixed-methods longitudinal outcomes study of Coolmine Therapeutic Community.1 The key finding of the study is that, despite the many instances of relapse, the positive impact of all CTC programmes on clients is undeniable. Overall, substance use declined, physical and mental health improved, and clients demonstrated improvements with regard to housing, employment, education and family relationships.

The primary aim was to track CTC clients over two years, gathering data on treatment retention, substance use, physical and psychosocial health, social functioning and criminal activity. The study also aimed to compare outcomes for clients of CTC’s three treatment programmes – male residential (the Lodge), female residential (Ashleigh House) and the mixed-gender drug-free day programme (DFDP).

Method

The mixed-methods study included quantitative information on 144 participants, and 86 qualitative interviews with 28 participants, which allowed for in-depth exploration of issues.

Quantitative data collection commenced in February 2011 with interviews taking place at baseline and at six-monthly intervals over the next two years. At baseline, the 144 participants recruited to the study were entering a primary treatment service at Coolmine Therapeutic Community. Qualitative interviews also took place at six-monthly intervals, starting in March 2011 and continuing for two years.

Qualitative data were collected from voluntary participants ranging in age from 20 to 47 years through semi-structured interviews at six-monthly intervals. The average of those in this sample was 32 years. CTC’s three primary treatment programmes were almost equally represented in this sample, 16 (58%) of whom were male and 12 (42%) female. While 86% of participants reported opiates as their primary problem drug, poly-drug use was common.

Findings

The study found an improvement in nearly all measured outcome areas over the two years of the study. Some programme-based and gender-based differences in treatment pathways, experiences and outcomes were uncovered.

Treatment retention, substance use and outcomes

At treatment intake all 144 participants were actively engaged in one of CTC’s three programmes. At the final 24-month data collection phase, 77.1 per cent (n=111) were retained in the study, and of these, 72 per cent (n=80) were reported to be drug-free. Thirty-six per cent of this final sample (n=40) had graduated from their programmes, and 85% (n=34) of these reported being drug-free at 24 months. In other words, the number of clients reporting drug-free status was approximately double that of those who graduated.

The proportion of participants who reported using illicit drug use in the 30 days preceding data collection fell from 43.1 per cent at baseline, to 35.5 per cent at one year and 27.9 per cent at two years. This relapse rate was relatively low compared to rates reported in a recent (2013) systematic review of therapeutic communities (25%–55%).

Graduation rates varied by programme – from 26.7% (n=8) for female residential clients (Ashleigh House), to 36.5% (n=19) for male residential clients (The Lodge) to 50% (n=9) among those on the drug-free day programme (DFDP). Self-discharges were highest among residential women (53.3%, n=16), next highest among clients of the DFDP (44.4%, n=8), and noticeably lower among male residential clients (21.2%, n=11). However, discharge owing to violation of a CTC protocol was highest among residential men (28.8%, n=15).

The authors comment that it is not clear to what extent women discharged early owing to the apparent lack of community cohesion and general incompatibility with key treatment elements in Ashleigh House (see below under Quality of Life), or owing to their own personal circumstances such as family obligations or psychological needs. The authors suggest these factors were in all likelihood interdependent.

The authors highlight how the circumstances surrounding an individual’s entry into treatment influenced the treatment outcome – whether the entry was ‘self-motivated’ (the client decided individually and autonomously to enter treatment), ‘incentivised’ (the client entered following a negotiated, suspended prison sentence), or a combination of the two (the client was self-motivated to achieve abstinence but also faced tangible external pressure to comply with treatment). Those who had expressed high levels of self-motivation from the outset were more engaged with the therapeutic programme than those who entered out of a sense of obligation or pressure (i.e. incentivised clients), and this disparity became more apparent as time went on.

The authors also report that motivation was noticeably stronger among clients on the drug-free day programme than clients on the residential programmes. Clients on the day programme reported entering after completing a separate residential programme; they were thus entering treatment after a period of sobriety and with previously acquired knowledge of treatment programmes. In addition, as the day programme was an optional extra after the residential programme, these clients tended to be highly committed to actively practising recovery.

Physical health and psychological health

Although women’s physical health, mental health and self-reported well-being were all lower than men’s on entry to treatment, the mean physical health scores of both increased (males: 11.62 at baseline to 14.49 at two years; females: 10.28 at baseline to 13.05 at two years), as did the mean psychological health scores of both (males: 11.43 at baseline to 12.97 at two years; females: 9.6 at baseline to 13.18 at two years).

The participant interviews reflected the quantitative findings. While many reported on-going health problems, including serious and chronic co-morbidities such as HIV and hepatitis C, most who remained drug-free in their final interview reported that their physical health was markedly improved. Positive mental health was often reported as having to be actively maintained, e.g. through participating in fellowship meetings or adhering to a structured daily routine. Female participants were more likely than males to report mental health issues, such as periods of depression, anxiety, self-harm, suicide ideation and suicide attempts.

Quality of life

The mean quality of life score showed a similar upward trend for both men and women (males: 11.62 at baseline to 13.91 at two years, females: 10.29 at baseline to 13.36 at two years). Improvement in overall quality of life was also reflected in the qualitative data. However, while engaged with CTC, men and women seem to have responded differently to some elements of the therapeutic programme.

Broadly speaking, men responded positively to group living, including the communal residential spaces, the shared chores, and the group therapy. Several of the women, however, struggled with the group element of residential treatment including the group chores and group sessions. Some of the women who had their children with them in Ashleigh House reported that they felt detached from the group-treatment experience, particularly unstructured group time, when compared to those who did not have children in residence with them, as they struggled to balance parenting and participation.

Housing

The proportion of participants reporting acute housing difficulties rose from 21.7 per cent at baseline to 22.8 per cent at two years. According to the authors, this increase may have been related to the fact that many clients at intake were engaged in CTC or another formal treatment service and were not experiencing acute housing problems. The majority of participants who were interviewed reported relying on housing services for assistance in securing housing and many found clean, safe and comfortable places to reside. But for some, owing to prior periods of homelessness and incarceration, the experience was challenging and far more precarious.

Education and employment

Both male and female clients were distinctly more active in their attempts to engage with education and the labour market after engaging with CTC. The proportion engaged in paid employment increased from 3.5 per cent at intake to 25 per cent at two years, and the proportion enrolled in education increased from 1.4 per cent to 17 per cent. Qualitative data revealed that the main difficulty in finding paid employment was a lack of formal education qualifications, leading many participants to consider returning to education. Because maintaining abstinence was viewed as the most immediate and important goal, a considerable number of participants expressed a preference for employment that was not overly demanding stress-inducing. Some participants reported being unable to secure employment owing to their past criminal activity.

Criminal activity

Qualitative data revealed that most participants had a background involving some level of criminal activity, much of it associated with supporting a lifestyle largely focused on drug acquisition and use. This was particularly the case for male participants. The proportion of participants who reported committing a criminal act in the 30 days preceding data collection fell from 8.6 per cent at baseline to 1.8 per cent at two years.

Conclusions

Despite the many instances of relapse, the authors conclude that the positive impact of all CTC programmes on clients is undeniable. Overall, substance use declined, physical and mental health improved, and clients demonstrated improvements with regard to housing, employment, education and family relationships. Many clients cited the tools they had acquired in treatment as key mechanisms for continued change. Some participants suggested ways in which CTC services could be improved and the authors suggest these ‘key messages’ could be applicable not only to CTC but to drug and alcohol therapeutic communities more generally: 

• flexibility in delivery of programmes, e.g. scheduling, structure, treatment timeline, multiple programming options;
• additional-one-to-one support;
• smaller group sessions;
• more support for residential clients moving from residential treatment into community housing with peers;
• day programme as step-down after completing a residential programme; and
• motivation enhancement.

Babineau K and Harris A (2016) Pathways through treatment: a mixed-methods longitudinal outcomes study of Coolmine therapeutic community Dublin: Coolmine Therapeutic Community. https://www.drugsandalcohol.ie/25091/