Saudi addiction therapeutic communities:Are they implementing the essential elements of addiction therapeutic communities.

OBJECTIVE: To investigate whether Saudi therapeutic communities (TCs) implement essential elements of TCs.
METHODS: This is a cross sectional study where the author visited all of the Saudi addiction TCs between September and December 2014. At least one week was spent in each TC, attending many therapeutic activities, reviewing patient files and program documents, and interviewing directors, treating teams and residents. At the end of each visit, a short version of the Survey of Essential Elements Questionnaire (SEEQ) was conducted, which is a reliable tool to evaluate the essential elements of TCs.
RESULTS: In 2014, there were only 5 TCs in Saudi Arabia. All of them were traditional TCs for adult male residents. The average total score was 3.72 out of 5 on the SEEQ. Regarding the 6 dimensions of the SEEQ, the TCs scored 4.15 on the TC perspective, 3.72 on the agency treatment approach and structure, 4.40 on community as therapeutic agent, 2.60 on educational and work activities, 3.50 on formal therapeutic elements, and 4.3 on process. There were no significant differences in dimensions scores among the 5 Saudi TCs.
CONCLUSION: In general, all of the Saudi TCs scored fairly high on the SEEQ, which may reflect a sufficient implementation of the TC as a therapeutic model. Educational and work activities lagged behind the other dimensions and should be improved and reevaluated.

Addiction therapeutic communities (TCs) are long-term, drug-free residencies where social learning and family models are the main underlying mechanisms of treatment.1,2 “Community as method’’ is the major approach of the TC, where residents’ interactions, participation in taking care of their residence, sharing of responsibilities, role models and support of TC workers and other residents, play a key therapeutic factor.1 The TCs view drug misuse as deviant conduct, reflecting obstructed personality maturation or incessant deficiencies in relational, educational, and financial abilities.3 Addiction TCs aim for clients’ abstinence of substance misuse; however, addressing the needs of the resident as a whole person – through overcoming antisocial behaviors, holding jobs and developing new holistic values and implementing lifestyle changes – are the major targeted goals of TCs.1-3 The TCs provide a safe and drug free environment where peers (residents) support each other, take responsibility for keeping themselves abstinent and advancing in recovery (improvement in all aspect of health). Residents taking care of the daily operations. Old residents made major contribution in TCs through representation of role models for new residents. Most TCs have staff that help residents recover and rehabilitate through treatment, educational, vocational, and life-skills teaching activities. In traditional TCs, the duration may last up to 24 months or more, but should not be less than 9-12 months, with overnight stay, mainly for adult men. Residents with debilitating major mental illness are usually excluded. However, modified TCs shorten the duration, include women, adolescents, and residents with comorbidities or special needs, and may not require overnight stays.2

The addiction TC is an approved and effective long-term approach to treat alcohol and substance use disorders with an efficacy that has been documented and replicated in many studies and national evaluation projects.4-12 The effect of the TC is not limited to sobriety but is extended to general and psychological health,13-15 employment,16 criminality9 and recidivism.17 In order to generalize these results, TCs need to implement approaches and components that represent the essence of the TC model of treatment. However, in recent years there has been an expansion and modification in TC models such that some new TCs may not actually be true TCs.3 Minimal research has been carried out to test the implementation of these core elements. Melnick and De Leon created a Survey of Essential Elements Questionnaire (SEEQ) based on the TC’s theoretical background in order to help define the essential components of a given traditional or modified TC.3 This survey became a major tool used in the USA and Europe to investigate and compare between addiction TCs.18-20 In the first study to clarify the nature of addiction TC treatment components,3 results showed high concordance among directors of 59 members of Therapeutic Communities of America (TCA) toward essential elements of SEEQ. The same results of what is regarded as major components of addiction TCs were replicated by using short form of SEEQ tool in 19 addiction TCs in USA.18 Although, modification to certain components of TCs are conceivable without losing the essence of TC model, however adjustments of the structure or to the intensity of the addiction TC intervention may have a critical sway on adherence to the TCs’ essential omponents.19 European addiction TCs share the same concepts and scored high on the SEEQ views regarding major treatment elements in the TC model.20

In the Kingdom of Saudi Arabia, there were only 5 addiction TCs at the time of conducting this study. All of them followed the traditional model, serving only adult males. The first of these TCs opened at Alamal Complex for Mental Health in Dammam in 2000. The residents were referred from the Alamal addiction treatment department after detoxification and completion of a short-stay treatment program (usually less than 4 weeks). Some residents who found it difficult to maintain sobriety after discharge, were referred directly from after-care services. It took 9 years to establish a second TC in Jeddah (2008) and a third one in Riyadh (2009). These 3 TCs are governmental and affiliated with large addiction treatment centers (Alamal complexes), whereas the remaining 2 TCs are operated by non-profit organizations in Dammam (2009) and Taif (2013).21 All of these TCs provide free services for their residents. A literature search of PubMed, Google Scholar and by approaching these TCs directly was conducted to revise the previous researches related to Saudi addiction TCs. However, there was a lack of published studies or data on Saudi TCs in these resources. The aim of this study was to investigate whether Saudi addiction TCs implement the essential elements of TCs, as determined by the short version of the SEEQ, which may reflect the implementation quality of this effective model in the Kingdom.

Methods

Sample and data collection

As part of a national study to evaluate addiction TCs in the Kingdom of Saudi Arabia, the author visited all Saudi addiction TCs (in Saudi Arabia, there are only 5 TCs) in September, October and November of 2014. At least one week was spent in each TC, evaluating infrastructure, policies and procedures, treatment and rehabilitation programs, and staff competencies. Many tools were used in the evaluations, including questionnaires for residents and treatment teams; interviews with directors, treatment teams and residents; observations of TC approaches and activities; and reviews of documents and residents’ files.18 At the end of each TC visit, using these observations and tools, a short version of the SEEQ was completed. The Internal Review Board of the College of Medicine, Al Imam Muhammad Ibn Saud Islamic University, Riyadh, Kingdom of Saudi Arabia ethically approved the design and execution of this study.

Instrument

The survey instrument consisted of the SEEQ, which is the most well studied and validated questionnaire to investigate the essential elements of TC. Melnick & De Leon developed the SEEQ constructs (dimensions, domains, and items) based on a theoretical framework of the TC treatment model.22,23 A national panel of 11 TC directors and one research expert conducted a modified Delphi process of the questionnaire and made further modifications and amendments after an extensive review.3,20 The final questionnaire contained 135 Likert-type items arranged in 6 broad dimensions highlighting the different components of TC treatment, and 27 domains reflecting the core philosophy and essential components.3,18,20 Respondent evaluated every item with the accompanying scale: 0=Objectionable; 1=Very Little Importance; 2=Some Importance; 3=Moderate Importance; 4=Fairly Important; 5=Extremely Important. For this study, the short version of the SEEQ was used, which amended the original SEEQ by condensing and consolidating different items per domain into one statement ().18,20 The original SEEQ demonstrates high overall reliability, with a Cronbach’s alpha value of 0.97. The short version of the SEEQ exhibited Cronbach’s alpha values of 0.81 and 0.85 in 2 independent samples,3,20 suggesting that it has an acceptable reliability.

Table 1

Survey of Essential Elements Questionnaire (short version) domain scores utilized at TCs in Kingdom of Saudi Arabia.

Domains statements	Riyadh	Dammam	Bedaiyah	Jeddah	Taif	Mean
The TC perspective
“Drug abuse” reflects general coping problems	5	5	4	4	5	4.6
“Drug abuse” rooted in developmental and psychological problems	4	4	3	3	4	3.6
“Recovery” involves global changes in identity, behavior, and lifestyle	4	4	4	4	5	4.2
Right living includes self-reliance and positive attitudes	4	4	4	4	5	4.2
The agency: treatment approach and structure
Agency follows a daily structured routine	4	5	5	4	5	4.6
Treatment approach is centered on member participation	3	3	3	3	2	2.8
Staff functions as members of the community	3	4	3	3	4	3.4
Clients are members of the community	4	4	5	4	4	4.2
Educational classes are provided on health-related issues	4	3	3	4	4	3.6
Community as therapeutic agent
Peers as gatekeepers protect community values	4	4	5	5	4	4.4
Peers provide mutual self-help	4	5	4	4	4	4.2
Daily activities emphasize community participation	3	4	4	4	3	3.6
Contact with outside community	4	4	5	4	4	4.2
Community hierarchical organization includes status and privileges	5	5	5	5	5	5
Community uses sanctions for norms violations	5	5	5	5	5	5
Periodic formal community surveillance	4	5	4	4	5	4.4
Educational and work activities
Academic and/or vocational training is available	2	3	2	2	3	2.4
Life skills training is available	2	2	2	2	3	2.2
Work is an important part of the therapeutic program	3	3	4	3	3	3.2
Formal therapeutic elements
Behavior is either reinforced or confronted	4	4	4	4	5	4.2
Frequent group activities reinforce community norms	3	4	4	3	4	3.6
Counselors are role models of community norms	3	4	3	3	4	3.4
Family members are included as part of therapy	3	3	2	3	3	2.8
Process
Phase progression from orientation to primary to re-entry	5	5	5	5	5	5
Orientation focuses on client assimilating into the community	4	4	4	4	5	4.2
Primary treatment focuses on developing prosocial norms	3	3	3	3	3	3
Re-entry prepares client for transition to outside community	5	5	5	5	5	5

Data analysis

Data were collected and stored in Microsoft Excel 2010, then coded and imported into Statistical Package for Social Sciences, version 20.0 (IBM Inc, Chicago, Illinois, USA) for analysis. Mean and standard deviation were calculated for each domain for all TCs and for all dimensions of each TC. One-way analysis of variance (ANOVA) was used to determine whether there were any differences in scoring among the TCs. The confidence interval was set at 95%, where a corresponding p-value<0.05 was used to identify statistical significance.

Results

The average total score of Saudi addiction TCs on the short version of the SEEQ was 3.7 of 5 (). On the individual dimensions, the TCs scored 4.2 on the TC perspective 4.15, on the agency treatment approach and structure 3.72, on community as therapeutic agent 4.40, on educational and work activities 2.60, on formal therapeutic elements 3.50 and 4.30 on process (). There were no statistically significant differences between the TCs in the dimension scores (). The TCs scored 3 and over on all domains () except “academic and/or vocational training is available” (2.4), “life skills training is available” (2.2), “treatment approach is centered on member participation” (2.8), and “family members are included as part of therapy” (2.8).

Table 2

Mean Survey of Essential Elements Questionnaire (short version) dimension scores among TCs in the Kingdom of Saudi Arabia.

Dimensions	Riyadh	Dammam	Bedaiyah	Jeddah	Taif	Overall Mean	ANOVA
Therapeutic communities perspective	4.25 (0.50)	4.25 (0.50)	3.75 (0.50)	3.75 (0.50)	4.75 (0.50)	4.15 (0.41)	0.082
Agency: treatment approach and structure	3.60 (0.55)	3.80 (0.84)	3.80 (1.10)	3.60 (0.55)	3.80 (1.10)	3.72 (0.70)	0.975
Community as therapeutic agent	4.14 (0.69)	4.57 (0.53)	4.57 (0.53)	4.43 (0.53)	4.29 (0.76)	4.40 (0.49)	0.689
Educational and work activities	2.33 (0.58)	2.67 (0.58)	2.67 (1.15)	2.33 (0.58)	3.00 (0.00)	2.60 (0.53)	0.586
Formal therapeutic elements	3.25 (0.50)	3.75 (0.50)	3.25 (0.96)	3.25 (0.50)	4.00 (0.82)	3.50 (0.58)	0.400
Process	4.25 (0.96)	4.25 (0.96)	4.25 (0.96)	4.25 (0.96)	4.50 (1.0)	4.30 (0.95)	0.983

No statistical significant value at 0.05, standard deviations are shown in parentheses, TC - therapeutic communities

Discussion

Addiction TCs in the Kingdom of Saudi Arabia scored fairly highly on the SEEQ questionnaire, which reflects a good implementation of the TC essential elements. This scoring is not far from American and European TCs scores.3,19,20 However, the Saudi TCs were rated by an independent addiction TC expert who stayed at and observed each TC for one week, rather than a TC director, which may add more validity to the scores and reduce conflicts of interest. This achievement is shared by all Saudi addiction TCs, which may reflect the strict standards and policies held by the related licensing authority. The Dammam addiction TC was the first and only TC in Saudi Arabia for more than 9 years, serving as a role model for the development of other addiction TCs, which may provide another explanation for the high scoring and lack of variability between the Saudi TCs. They scored between 3.3 and 4.3 out of 5 in all dimensions except educational and work activities, which had an average score of 2.8. The low scoring in this dimension was observed in all TCs, which may reflect a lesser focus on academic, vocational and life skills training. Saudi TCs scored even 3 or more in all domains of other dimensions except in 2; however, each of these scores was limited to a single TC.

In conclusion, it seems that Saudi TC have succeeded in implementing TC model properly. However, the essential components of this model tested by SEEQ may need special adaptation to the social culture and values. Vocational; life-skills training, and work activities are essential elements of TCs and represent major elements in rehabilitation programs to which Saudi TCs aspire. Low scoring in this dimension warrants further studies to analyze the situation, investigating for the causes and suggesting solutions. Although the existence of the essential elements in the Saudi TCs may point indirectly to treatment efficacy through good quality program implementation, other elements of TCs like infrastructure, treatment team competencies, resident and family satisfaction, and quality of services have to be evaluated to properly gauge Saudi TC efficacy. A longitudinal outcome-based effectiveness study would be the best measure of Saudi addiction TC efficacy.