Development of the therapeutic alliance and process of change in a therapeutic community.The perspective of drug addicts.

Resumo

The creation of hierarchical therapeutic communities for the treatment of substance dependence was initially based on a self-help movement. Only afterwards was this model appropriated by psychotherapeutic professionals. At the same time, studies about the efficiency of this model have demonstrated its validity in the treatment of substance dependence. However, similarly to psychotherapies and the various psychological interventions used in the treatment of substance dependence, it also became evident that it was necessary to study how change happens in therapeutic communities. Thus, the main objective of the present work is to study the process of change in therapeutic communities. To achieve this objective we have used a mixed methodology: we have carried out a quantitative and a qualitative study. We used a longitudinal and prospective research design with three groups of participants each corresponding to a different phase of treatment. The majority of the 25 participants were male (76%), with an average age of 32.6 (SD=7.0) and an average schooling of 9.3 years (SD=2.3). The main drugs of dependence were heroin and cocaine. In average, the use of those substances began when participants were 20 years old and continued for ten years. Approximately half of participants (52%) had a history of intravenous drug abuse. The first study used a quantitative approach and its goal was to analyse the process of change by describing the evolution of the therapeutic alliance during treatment, the variable contributing to its evolution and their association with therapeutic outcomes. We observed that for each factor of the therapeutic alliance there was a corresponding evolution profile. In relation to the bond factor, we observed that: (1) the bond evolved stably during the three phases of the therapeutic process that were studied; (2) higher values in the bond factor at the beginning of a phase were associated with the conclusion of that treatment phase; (3) the depressive symptomatology negatively affected the establishment of the bond at the beginning of the phase, regardless of whether participants concluded the phase or not. Regarding the factor goals and tasks, we recorded that: (1) this factor increased during the three treatment phases; (2) although the slope did not change with phase, the value of the factor at the beginning of the phase was higher when participants were in a more advanced phase of treatment. The second study used a qualitative approach and its aim was to investigate the construction of theories of change - in reference to each of the treatment phases as defined in the therapeutic community - based on the perspective of change held by the substance dependent subjects undergoing treatment and has led to the conclusion that for each phase of treatment there was, in the community, a corresponding specific theory. The first theory, entitled I-Object, stressed the need of the substance dependent subject to perform a self-observation movement to assume the addiction, to share feelings and commit himself or herself to treatment. The second theory, I-Action, revealed the perception that change depends on oneself, that is, change was implemented to the extent that the subjects considered that to "do things differently" produced changes in the relationships with others and with oneself. The third theory, ITherapeutic, refers to the strengthening of inner self-understanding skills and to the perspective of an autonomy based on a plan for the future. The present study allowed to understand the essential role of pro-active mobilization for change (self-help) of community residents, and the presence of a collaborative relationship - the therapeutic alliance - associated with the therapeutic process which influences the decision of substance dependent subjects to remain in treatment.