Gómez-Restrepo et al.

Substance Abuse Treatment, Prevention, and Policy

(2017) 12:53
DOI 10.1186/s13011-017-0129-y

RESEARCH Open Access

Quality measurers of therapeutic

communities for substance dependence: an
international collaborative study survey in
Latin America
Carlos Gómez-Restrepo1* , Patricia Maldonado2, Nelcy Rodríguez1, Rafael Ruiz-Gaviria1, Miguel Ángel Escalante3,
Raúl Ángel Gómez3, Marcelo Ribeiro de Araujo4, Ana Carolina Schmidt de Oliveira4, Joel Salvador Chávez Rivera5,
Jorge Alberto Godínez García6, Marina Piazza Ferrand7 and Dora Blitchtein-Winicki8

Abstract
Background: In Latin America, substance related disorders are highly prevalent and one of the treatment strategies
is the Therapeutic Communities (TCs), however, in Latin America there is scarce data about this treatment strategies,
their quality, drop-out rates and patient satisfaction.
Methods: Based on a previous study in 5 Latin American countries, the TCs who had a score equal or higher than 9
according to the De Leon criteria which are some fundamental items that the TCs should meet, were selected to carry
out a descriptive and retrospective study of qualitative and quantitative characteristics of the TCs.
Results: Data from 58 TCs in 5 countries were included, with a sample of 1414 patients interviewed, of which most
were single men, with no hospitalization history in a therapeutic community. Marijuana was the most commonly
substance used in the 30 days prior to hospitalization, with 78% of interviewees referring alcohol consumption in
the last 6 months and an average onset of psychoactive substances at 16 years of age. A 79% of the patients
interviewed perceived some improvement during their stay in the TCs. The less fulfilled Quality Indicators by the
TCs were “Requesting a professional qualification to former addicts that belonged to the program” and “Work as
part of the therapeutic program”. Among the reasons for discharge found in the database, 44% were due to
therapeutic discharge with fulfillment of the treatment plan and 44% withdraws.
Conclusion: The user satisfaction with TCs, in terms of infrastructure and quality are quite high, as the fulfillment of
essential quality items, however, the follow up information to evaluate effectiveness of the treatment is poor or in
some cases unknown.
Keywords: Therapeutic communities (TCs), Substance-related disorders, Patient satisfaction, Patient compliance

Background alterations that affect the individual suffering from such

Use of psychoactive substances (PSs) is one of the psychi- diseases [4]. In addition, use of PSs, is accompanied by in-
atric disorders that has generated great interest from gov- creased risk behaviors, traffic accidents and co-infection
ernments because of the economic, political, social and with diseases like HIV and Hepatitis C virus [1, 5, 6].
health implications of their consumption [1–3]. Chronic In a study conducted by the World Health
use of these substances generates molecular and cellular Organization (WHO)with several countries in different
changes that will effect in behavioral and lifestyle regions of the world, including Europe and the Ameri-
cas, evaluating the prevalence of alcohol use disorders or
* Correspondence: cgomez_restrepo@yahoo.com other psychoactive substances in the past 12 months, a
1
Department of Clinical Epidemiology and Biostatistics, Hospital Universitario prevalence from 5.8% in Mexico to 13.2 in Germany [7]
San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia
Full list of author information is available at the end of the article
was found. The prevalence of such pathologies is not a

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 2 of 9

negligible value taking into account the consumption of the database of the available TCs obtained in that study
any substance, if we review that the substance use disorder it is intended to identify the sociodemographic variables,
accounted for 0.5 of the total years of life lost (YLL) consumption patterns, user perception of effectiveness,
worldwide, emphasizing that the most affected population fulfillment of the treatment plan and follow up of the
is in the age group between 15 and 30 years [8] (6). users in the same 5 countries that provided the database
Nowadays the management and support of patients with of the TCs.
substance use disorders are very wide but their objective is
helping them to avoid use of the substance and abandon Methods
drug seeking behaviors. Despite the treatment and com- Based on the study conducted in 2013 which identified
mitment of the patient to the management, research has all the available TCs who accepted to participate and an-
shown relapse rates of up to 40 or 50%, so the treatment swered a questionnaire about their structure, therapeutic
has to be done in more than one occasion [9]. plans and were evaluated according to the De Leon cri-
One of the treatmen or management options are the teria(These are 12 essential items established by a group
TCs. These are self-help programs for abandonment of of authors that should be accomplished in order to de-
harmful substance use behaviours and health recovery of liver quality care to the users) [18, 19]. The TCs that ob-
the patient through an individual personal growth, that is tained a score equal or higher than 9 points according to
performed separating the subject from society and submit- De Leon criteria were selected (See Table 1). TCs were
ting the patients in a specific community with professional excluded if they exclusively worked as an outpatient
staff and other patients with substance use [10, 11]. basis or whose target patients was exclusively minors or
TCs have proven to be effective in helping the patients took care of fewer than 50 patients or if their therapeutic
abandon the active consumption of the substance, plan was less than 30 days. Once the sample of TCs that
returning to their jobs, improving mental health and fulfilled the selection criteria and were willing to partici-
quality of life and also increasing the time to relapse and pate was established, a random number was generated
drug-free periods [12–15]. considering a simple distribution. With the subsequent
In the longest study conducted by the National Insti- setup of the TCs in a list and then selecting TCs from
tue of Drug Abuse (NIDA), the DATOS study (Drug each country.
Abuse Treatment Outcome Studies) included more than Once selected the TCs in each country, visits were
10,000 patients and compared the effectiveness of differ- made to each of them for descriptive user surveys on
ent therapeutic options for substance use, including socio-demographic variables, perceived quality and ful-
TCs. The study showed that in those patients treated fillment of the therapeutic plan of TCs, as well as con-
with this modality there was a reduction of heroin, co- sumption patterns of patients from the TCs contacted
caine and alcohol use after 1 and 5 years of fulfilling the and who were willing to continue participating in the
treatment. Besides, this study also showed increased pa- study. The surveys were made by previously trained.
tient employment rates after the end of the treatment, Patients eligible for the survey were those who had en-
proving through different outcomes measures the effect- tered the TCs early 2009 or late 2012. The questionnaires
iveness of the TCs [16].Despite that some studies have used were translated to portuguese for the participants of
shown the impact of the TCs, not all the TCs fulfil the Brazil, and adapted to each of the other countries in order
quality standards recommended by the World Feder- to improve the reception of the user who were willing to
ation of Therapeutic Communities (WFTC). This vari- participate in the study. These questionnaires were created
ability can explain the different in the success and by the group and were administered by previously trained
relapses rates [14]. representatives in each country.
Studies of the amount, quality and need of the TCs The questions evaluating the perception of TCs from
has been done mostly in USA [16] and Europe [17]. very the users were scored from 1 to 5, 1 meaning completely
few studies have been conducted in Latin America that unsatisfied and 5 completely satisfied. For the question
identify and describe the characteristics of the people at- of improvement perception the answers were also classi-
tending these facilities, the pattern of substance use, sat- fied from 1 to 5, being 1 not improvement and 5 totally
isfaction and perceived effectiveness of these treatments improvement.
by users, and the follow up of the patients who fulfilled Additionally, a retrospective data gathering was carried
the therapeutic plan. out by applying surveys to the TCs directors, requesting
In a previous study conducted in Latin America by the information on drop outs, admissions and therapeutic
same authors and in collaboration with Latin American discharges in the three years prior to the study. Except 3
Federation of Therapeutic Communities (LAFCT) that Argentinian TCs that were selected and refused to pro-
identified the TCs, available and their respective quality vide the information requested, the rest did not object to
in Argentina, Brazil, Colombia, Mexico and Peru. Using deliver the required information.
Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 3 of 9

Table 1 De Leon criteria [18, 19]

Component Brief description
Planned duration of the treatment The length of the treatment will be adjusted to the individual
needs of each patient.
Alienation from the community In a residential context, the patients will be kept away from the exterior
community 24 h a day for at least some months, before acquiring privileges
of permit
Community activities Excepting the individual counseling, all the activities are scheduled i community
with the other residents
Staff roles and functions Independently of the professional function, each member has to fullfill the function
of community member. For this reason, the mission from each member of the staff
is to provide help and aids according to the method of community self-help
Residents as role model The members who show expected conducts and capture the values, ideas and beliefs
of the community are used as role model for the other residents
Structured day The activities are daily planned in order to distract de residents from their cravings,
thoughts about consumption and drugs, and also from the routine of their daily living
Job as therapy and education According to the methodology of self-help, all the members are responsible of the daily
management of the facilities. The work is distributed among the users creating
responsibilities and duties with education and therapeutic goals
A vision of recovery and right living There are some established concepts in the methods used by the Therapeutic community
to instruct about topics around the rehabilitation and drug cessation through the self-help
methodology
Meeting groups between residents The common sense of conducting this kind of meeting is to create awareness in each
patient about patterns and attitudes related to the pattern of consumption that could be
identified sharing their experiences with other residents of the community
Awareness training The main goal of all the therapeutic or educational is to increase self-awareness of the
individual about the consequences, impacts and repercussions of their previous conducts
and attitudes in themselves and in their social environment.
Personal growth training To achieve this goal, the community should guarantee education and instructions to the
patient of how to identify their own feelings with their respective management and expression
in a constructive way and how to share them in community.
Care continuity Fulfilling the treatment plan, with the goals of increasing self-awareness and change of their
vision based in the community and self-help method is the firs step. After this, a network
between the user and community should be established in order to keep the process of
continuous personal and growth and providing personal experiences to newcomers.

After obtaining all patient oral and written informed Colombia with only 7 TCs (12%). Most people interviewed
consent, questionnaires, and having collected the required were men, accounting for 92% of the surveyed sample, the
information from the TCs directors, information was inte- most common marital status was single, accounting for
grated into a Microsoft Excel database. The datasets used 62% of the sample. Regarding employment status, 53% re-
and/or analyzed during the current study is available from ported being employees prior to his admission to the TC,
the corresponding author on reasonable request. and 46% were unemployed. (See Table 2).
This study was conducted with according to the prin-
ciples established by the 2000 Helsinki Declaration. The
study also counted with the approval of the ethics and Consumer age and previous hospitalization
review board from each of the Universities or Institu- The age of first use of any non-alcohol PSs varied greatly
tions involved in the study. across countries, being the lowest Mexico with first in-
take made at 4 years of age. As for the older age of first
Results use of a substance, it was reported in Brazil with a report
Therapeutic communities selected and number of of 53 years of age. Unlike the consumption of younger
participant users and older age, the average age was very similar between
In all, 58 TCs, with 1414 users were interviewed, though different countries, generally averages between 15 and
much of the information from users of TCs in Argentina 16 years of age (see Table 3).
was not complete and therefore not included in some In terms of number of previous hospitalizations, 684
analysis of sample data. users (65%) reported not having been previously hospi-
The country that provided more participant TCs was talized, 369 users (35%) reported having been hospital-
Brazil with 20 communities (34%), and less involved was ized at least once before, and 295 (28%) responded that
Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 4 of 9

Table 2 Number of TCs surveyed by country and unknown components) users (28%). Among the sub-
sociodemographic characteristics stances less reported are heroin powder (3%) and dick
n % (2%) (Liquid used for cleaning machines). (See Fig. 1).
Participant TCs by country Also inquiring among users of alcohol consumption in
□ Argentina 9 16 the last six months, asking about how many times in that
period, if had consumed more than 4 drinks if it was a
□ Brazil 20 34
woman, or more than 5 if it was male, in one day. 21% of
□ Colombia 7 12
respondents said no, 18% once, 60% more than once and
□ México 10 17 1% of respondents did not answer the question.
□ Perú 12 21
Interviewed users by country User satisfaction survey
□ Argentina 361 26 The user satisfaction questionnaire evaluated several
areas, such as admission, information on the TCs’ in-
□ Brazil 300 21
ternal rules, satisfaction with institution staff, as well as
□ Colombia 178 13
the improvement perception.
□ México 300 21 The first aspect evaluated (including reports from Ar-
□ Perú 275 19 gentinian TCs), was the complexity of TCs’ admission
Gender process by patient, which according to most respondents
□ Males 1298 92 (76%) were slightly or not complicated. In addition, 88%
of respondents reported that the staff explained to them
□ Females 116 8
in detail the institution rules and 68% of users reported
Marital Status
being satisfied with the attention time spent by medical
□ Single 673 64 personnel (See Table 4). The following data (not includ-
□ Married 168 16 ing reports from Argentina) provides information about
□ Divorced 95 9 satisfaction with TCs’ staff, including psychiatrists, psy-
□ Widower 11 1 chologists, nurses and other personnel. 76% were satis-
fied with the staff’s work at the institution.
□ Free Union 95 9
Less than 2% of users interviewed perceived little or
□ No Data 11 1
no improvement in their underlying conditions, this be-
a
Previous Work Activity ing a constant in most countries. Most TCs users per-
□ Employee 558 53 ceived improvement in their substance use problem,
□ Unemployed 484 46 represented by 54% of respondents, showing that the
□ No Data 11 1 users that participated in the study were perceiving some
a
Total number of patients was 1053, there was no data from Argentina
kind of improvement of their drug addiction without the
use of other therapies like drug replacement therapy or
they had been interned three times before their current an intense psychiatric management (see Table 5).
treatment.
TCs essential elements
Substance use Compliance with quality indicators and essential ele-
Users answered if they had consumed some substance ments in the sample selected of TCs were evaluated,
different from alcohol in the 30 days prior to their stay which included “organized and standardized treatment
in the TC, and identify the non-alcohol substance used. programs”, “family involvement in the treatment plan”,
The results across countries are similar, being marijuana “self-assessments of the therapeutic team”, etc. (Other
the most frequently (49%), followed by cocaine (41%) evaluated indicators, see Table 6). Most managers re-
and basuco (cocaine base paste, possibly mixed with ported meeting almost all the criteria, however, the only
country where all interviewed TCs met 100% of the
Table 3 Age at first use of substances items was Mexico. In Colombia, the least met indicators
Brazil Colombia México Perú Total were “work as part of the therapeutic program” (71%)
Age a
n n n n n
and “users are encouraged to “act as if” to develop a
more positive attitude” (71%).
Minimum 5 7 4 8 6
In Brazil, the element with the lowest compliance was
Maximum 53 45 46 48 48 “requesting professional qualifications to former addicts"
Average 16,1 16 15 16 16 this mean that if a former addict wanted to be an em-
a
There was no data from Argentina ploy of the therapeutic community, he was not asked
Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 5 of 9

Fig. 1 Most consumed substances in the participating countries except Argentina

about any degree or professional qualification in order institution” (31%), followed by “ignorance of the cause”
to be a worker in the TC.In Peru, the lowest score was (27%) and “lack of family support” (20%). Less frequent
the criterion of "The therapeutic program includes train- reasons were “not feeling comfortable with the institu-
ing in personal decision-making and social skills”. In tion’s staff” (1%) and “have not perceived any improve-
Argentina, despite the quality indicators were not met ment” (2%) (See Fig. 2).
by all communities, there was no indicator to be less sat- To analyze the reasons for patients discharge, 3461 in-
isfied compared to the rest. dividuals’ data was obtained, of which 44% were thera-
peutic discharge, i.e. completion of the treatment plan,
Retrospective data collection and 42% withdrew. For the remaining 14%, no data was
Data and medical records of the TCs who agreed to par- obtained. Finally, follow-up at one year of 795 patients
ticipate (including details of admission and discharge of main activity was collected, of which the vast majority
patients in the time period between the second half of (51%) was working, 25% were studying, 14% were un-
2009 and the first six months of 2012) were gathered. employed, 10% did not know and 2% do not have the
Should be clear that in this retrospective collection, data data (Fig. 3). The vast majority of these (71%) were con-
from the Argentinian participating institutions was not ducted by telephone communication, followed by visit-
obtained. Records of 3461 patients were obtained, of ing the TCs (23%) and the remainder is distributed
which 87% were male and 13% female. The ages of the among contact via e-mail or home visit.
individuals had a wide range between 13 to 79 years,
with an average of 30 years, showing the variability of Discussion
people who suffer from drug addictions. The findings of this study are the first in Latin America
The main reasons for abandonment were collected. A allowing adequate description of the TCs in our region
total of 1453 records(42%) were analyzed, in which the with a high amount of the user reporting a quite to to-
most frequent were “not feeling comfortable with the tally improvement just with this intervention . It is the
first study in this part of the world, and including five
Table 4 User satisfaction
countries allows proper identification of these institu-
N %
tions and regulates in a more uniform manner its exist-
Admission Process ence. This could help to the establishment of more rules
□ Not Complicated 785 56 and guidelines to unify and standardized the care deliv-
□ Slightly Complicated 287 20 ered by this type of institutions.
□ Very Complicated 64 4
Table 5 Improvement perception reported by users
□ Quite Complicated 50 4
Brazil Colombia México Perú Total
□ Have not participated in admission process 228 16
n % n % n % n % n %
Time spent by the doctor
Totally 83 29 68 38 52 16 55 20,0 258 25
□ Enough 959 68%
Quite 153 53,5 85 48 195 59,8 139 50,6 572 54
□ Not Enough 455 32%
Some 32 11,2 23 13 71 21,8 58 21,0 184 17
Information on the TCs’ internal rules
A Little 13 4,5 2 1 5 1,5 6 2,2 26 2
□ Yes 1258 89%
Not 5 1,7 0 0 3 0,9 6 2,0 14 1
□ No 156 11%
There was no data from Argentina
Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 6 of 9

Table 6 Indicators compliance by the TCs

Argentina Brazil Colombia México Perú Total
n % n % n % n % n % n %
The therapeutic program includes training in personal 9 100 20 100 7 100 10 100 8 67 54 92
decision-making and social skills
Recovery means for TC development of personal identity 9 100 20 100 7 100 10 100 12 100 59 100
and global change lifestyle
Users learn conflict resolution skills 9 100 20 100 7 100 10 100 11 92 58 98
The work is part of the therapeutic program 8 88 20 100 5 71 10 100 12 100 55 93
Users are encouraged to “act as if” to develop a more 9 100 19 95 5 71 10 100 11 92 55 93
positive attitude
Regularly seminars are held to help residents find a balance 8 88 19 95 6 86 10 100 12 100 56 95
between the emotional and cognitive experiences of the
TC program
Requesting professional qualifications to former addicts 8 88 10 50 6 86 10 100 11 92 45 76
Advisory services are provided to the user’s family 9 100 20 100 7 100 10 100 12 100 59 100
The TC has medical records and individual records for 9 100 19 95 7 100 10 100 12 100 58 98
monitoring and continuous evaluation of services
The TC has guidelines for developing an institutional climate 9 100 20 100 7 100 10 100 12 100 59 100
of trust and mutual support; It has a written declaration of
user’s rights and duties
There is a flowchart of the TC’s staff functions, which are known 9 100 20 100 7 100 10 100 12 100 59 100
and accepted by all
The TC periodically performs an assessment of its effectiveness 8 88 19 95 7 100 10 100 9 75 53 89
and efficiency, which includes user’s review and satisfaction

One of the first findings in our study was that up to of respondents were single, while in other studies such
90% of the respondents were men, which may be be- as Sadir et al. [23] only 48% were single. In our study,
cause the male are more likely to consume PSs com- the majority of respondents (53%) were employed before
pared with women, as issued in 2014 by the UNODC entering the institution, however, reports of employment
report [20]. Additionally, in a study conducted by status among TCs users are highly variable with employ-
Johnson et al. in Thailand, in which they evaluated 22 ment rates of only 17% in one TC in Australia [24], or as
TCs, most users were men [21]. The sexism or Macho high as 64% in Iran . One explanation of these differ-
culture spread through all Latin America also could ex- ences may be that in the countries were the study was
plain the greater proportion of male assisting to this conducted, most of the TCs are private or belong to a
communities because of the Taboo or bad image that religion and not public and supported by the govern-
this can cause in a woman. ment. This would make the entrance to this center more
Another finding of our study was that most users of difficult because some patients do not have the money
the TCs interviewed were single before admission to the or resources to access them.
program. These findings are similar to those found by The average age of first use of a non-alcohol psycho-
studies such as Fernández- Montalvo [22], in which 72% active substance was 16.1 on average for the entire

Fig. 2 Abandonment reasons

Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 7 of 9

Fig. 3 Actual activities of the user who ended their treatment plan

sample, a value that is similar to those found in other was simple. Another aspect evaluated that was not seen
studies for different countries in the region [25] and as in other references, was the user satisfaction with med-
reported by the UNODC [20]. Most patients in our sam- ical care and the health team. 68% of users are satisfied
ple (68%) had not reported any previous attempt of with the care given time, this may be because the pa-
entry into a TC, and only 28% reported to have entered tients who accept to go to the TCs hope that if they are
more than three times; these figures differ from those re- going to be intern in a drug-free residence their health
ported by a study in Iran [23] in which only 25% of re- should be more supervised than in other places.
spondents had less than two entry attempts to a TC Up to 79% of respondents perceived that they had had
facility and 75% had three or more attempts of entering enough or complete improvement in their condition
TCs for treatment. Another study conducted by Darke with the entrance to the TC, and less than 2% did not
[24] and colleagues found that up to 58% of patients feel any improvement. These findings are different from
interviewed had been admitted at least once in a TC those reported by Fernandez et al. [22], who found that
treatment . only 54% of users had perceived some degree of im-
The non-alcohol substance most frequently consumed provement and 46% had not felt any improvement or
in the last 30 days was marijuana, followed by cocaine deterioration in his health. These could be explained by
and basuco (cocaine base), but as mentioned earlier in differences in the users or the number of sample that
this article, the epidemiology of substances consumed had each of the studies. Other reasons may be how the
varies depending on the region. In a study in Thailand, improvement was evaluated if just by asking the patient
the substances most frequently consumed in the same or following them until they relapse or how long was the
period were stimulants (ecstasy, speed, ice), followed by period of abstinence. These differences mainly exist be-
inhalants and marijuana [21]. The study by Darke [24] cause there are no standardized measures of treatment
et al., found that the most commonly used drugs in the success of substance use which could limit the compari-
last six months were benzodiazepines, followed by sons between the results of different studies about man-
marijuana and heroin. agement of drug addictions. Another explanation could
The difficulty of getting admission of patients to the be the selection bias because only users who were active
TCs was evaluated by patients as slightly or not compli- in the program were interviewed, but not those who
cated showing that the main reasons for not using this abandoned the program. All these explanations could
kind of treatment for substance use are not related to modify the proportion of users feeling any improvement
the procedure related to the admission to the commu- in their condition.
nity; these results were similar to those found in the Evaluation of TCs’ quality indicators evidenced that
study of López- Goñi et al. [26], who found that most of Latin America meet most of the criteria, however, the
the interviewees reported that the entrance to the TCs criteria “requesting professional qualifications to former
Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 8 of 9

addicts” and “use the work as part of the treatment finding of our study are consistent with previous reports
plan”, were lower compliance indicators. Although there of the literature, but with the findings of the high satis-
are no studies that have used the same criteria we faction rate and the fulfillment of the essential criteria of
employed, there is another tool to assess the quality of the TCs it opens new doors in order to propose this
the TCs, known as SEEQ. This questionnaire contains method as an alternative for the management of drug
139 questions and it is narrowed to evaluated 6 dimen- addictions.
sions of the TCs in a likert-type questions from 1(very One of the weaknesses, was selecting centers that have
little importance) to 5 (extremely important) and is di- fulfilled a minimum score in the first phase of the study,
rected to the directors and staff of the community [27]. because this could have biased the interpretation of vari-
SEEQ was used in the Goethal et al. [17]study, in ables as the fulfillment of essential elements of quality,
which traditional and modified TCs were evaluated in as may have limited the selection of center users to
Europe and USA. Among the findings of this study they those with better qualifications, thereby reducing the
come upon that the criteria elements with lower scores possibility of extrapolating the findings of our study. An-
in European TCs were “process monitoring and evalu- other major limitation of both the study and participat-
ation of its programs”, and “ranking TCs staff members ing centers was the high proportion of missing
using an established organization chart”. As for the US information on variables as the length of stay of the pa-
TCs, the worst scores were achieved in the fields of con- tients, “reasons for abandonment”, monitoring and dis-
frontation and psychological problems arising from drug charges during the period in which the study was
use as well as family integration in user’s treatment. conducted. Selection bias could have modified the re-
The proportion of therapeutic discharges and aban- sults because only active users were interviewed for the
donments are very similar (44% and 42%), these data be- satisfaction and improvement status, but users who
ing different to studies in Australia [24] and Thailand already fulfilled their treatment plan were not contacted.
[21], where 17% and 33% of departures ended in aban-
donment and 34% and 66% in therapeutic discharges re- Conclusion
spectively. The main reasons for abandonment in our TC’s are one of the therapeutic options for the treatment
study were “not feeling satisfied with the institution”, of patients with substance use disorder, so the findings
“unknown reason” and “lack of family support”, being of this study showed that the participating TCs fulfilled
compared with another study by López- Goñi et al. [26] the minimum quality criteria to provide management to
agrees that the single most frequent reason for abandon- the patients and most of the patients are satisfied with
ment is “not feeling comfortable with the institution”. the received treatment. Despite, there is still room to im-
This finding points out a key question and problem of prove, especially in the follow up of the patients in order
the TCs designs and how its principles are being adopted to provide more complete data about the effectiveness of
by different institutions to make comfortable their users. this interventions in the patient in Latin America.TCs
This issue could be starting point in the design and con- are also widespread in the region and the knowledge of
duction of new studies to reduce this percentage of users how are they performing and their quality may allow
not feeling comfortable with the TCs. them to be more popular among the people of the re-
Close monitoring to some users, found that most of gion and the governments.
the patients were working or studying, and their activ-
ities were unknown in 10% of this sub-sample. These Abbreviations
HIV: Human Immunodeficiency Virus; LAFCT: Latin American Federation of
findings were also found in a longitudinal study in Spain Therapeutic Communities; NMHS: National Mental Health Survey;
[22], in which it was found that most users of the evalu- PSs: Psychoactive substances; TCs: Therapeutic Communities; UNODC: United
ated TC, whether they had completed treatment or not, Nations Office on Drugs and Crime; WHO: World Health Organization;
YLL: Years of life lost
were working. Despite these results, we can not
generalize it because of the small sub sample of user that Acknowledgments
were followed that represented less than 50% of the eval- Special thanks to Brazilian Federation of Therapeutic Communities (FEBRACT),
Colombian Federation of Therapeutic Communities (FECCOT), State Council
uated users. Against Addictions in Jalisco (CECAJ), Mexican Federation of Therapeutic
The collaboration of several Latin American countries, Communities (FEMEXCOT) Developing Life without Drugs (DEVIDA) by the
along with the large sample collected of TCs and users, Peruvian Ministry of Health (MOH), Peruvian Association of Therapeutic
Communities (PTCA), Centre for Information and Education for the Prevention
are the greatest strengths of our study, allowing to find of Drug Abuse (CEDRO), Argentine Drug Observatory (SEDRONAR), the Latin
the differences between the TCs available in the coun- American Federation of Therapeutic Communities (FLACT) and doctor Manish
tries, the most consumed substances, the consumption K. Mishra.
onset age and other variables that allow to find out the
Funding
quality of TCs among the studied countries and an esti- This study was financially supported by:. Corporative Foundations, A.C, USA
mate of the services available in our region. Most of the embassy in Peru, Bancolombia group S.A.
Gómez-Restrepo et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:53 Page 9 of 9

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The datasets used and/or analysed during the current study available from Global burden of disease attributable to mental and substance use
the corresponding author on reasonable request. disorders: findings from the global burden of disease study 2010. Lancet.
2013;382:1575–86.
Authors’ contributions 9. Instituto Nacional sobre el Abuso de Drogas, Departamento de Salud y
CG: The general coordinator in charge of retrieving and condensation the Servicios Humanos de los EE.UU. Principios de tratamientos para la
data from the five countries and was the main investigator in Colombia. Also drogadicción. Una guía basada en las investigaciones [Internet]. Estados
was in charge of supervising the redaction of the manuscript. PM and RR: Unidos; 2010 [cited 2015 Jun 4]. Available from: https://www.drugabuse.
Co-investigators who retrieved the data from the Colombian therapeutic gov/sites/default/files/podatsp.pdf
communities and compiled the results after the data was evaluated by the 10. De Leon G, editor. Community as method: therapeutic communities for
statistician from the group. Actively participated in the elaboration of the special populations and special settings. Westport, Conn: Praeger; 1997.
manuscript. NR: Was in charge of the design of the database with the 11. World Federation of Therapeutic Communities (WFTC). What is a
posterior depuration and analysis of the data from the 5 countries. ME and Therapeutic Community? [Internet]. Estados Unidos; [cited 2015 Jun 5].
RG: Main Investigators from Argentina who conducted the survey and Available from: http://www.wftc.org/therapeutic_community.html
retrieved the data from the Argentinian therapeutic Communities. MA and 12. Smith LA, Gates S, Foxcroft D. Therapeutic communities for substance
AS: Main Investigators from Brazil who conducted the survey and retrieved related disorder. Cochrane Database Syst Rev. 2006:CD005338.
the data from the Brazilian therapeutic Communities. JC and JG: Main Investigators 13. Johnson K, Pan Z, Young L, Vanderhoff J, Shamblen S, Browne T, et al.
from Mexico who conducted the survey and retrieved the data from the Mexican Therapeutic community drug treatment success in Peru: a follow-up
therapeutic Communities. MF and DW: Main Investigators from Peru outcome study. Subst Abuse Treat Prev Policy. 2008;3:26.
who conducted the survey and retrieved the data from the Peruvian 14. Fiestas F, Ponce J. Eficacia de las comunidades terapéuticas en el
therapeutic Communities. All authors read and approved the final tratamiento de problemas por uso de sustancias psicoactivas: una revisión
manuscript. sistemática. Rev. perú. med. exp. salud. Publica. 2012;29:12–20.
15. Vanderplasschen W, Colpaert K, Autrique M, Rapp RC, Pearce S, Broekaert E,
Ethics approval and consent to participate et al. Therapeutic communities for addictions: a review of their effectiveness
This study was conducted according to the Helsinki declaration and from a recovery-oriented perspective. ScientificWorldJournal. 2013;2013:
obatained approval from each of the institutions participating in the study. 427817.
Also, verbal and written consent from each of the patients was obtained. 16. Hubbard RL, Craddock SG, Anderson J. Overview of 5-year followup
outcomes in the drug abuse treatment outcome studies (DATOS). J Subst
Abus Treat. 2003;25:125–34.
Consent for publication
17. Goethals I, Soyez V, Melnick G, De Leon G, Broekaert E. Essential elements of
Not applicable.
treatment: a comparative study between European and American
therapeutic communities for addiction. Subst. Use Misuse. 2011;46:1023–31.
Competing interests 18. De Leon G. Therapeutic communities for addictions: a theoretical framework.
The authors declare that they have no competing interests. Int J Addict. 1995;30:1603–45.
19. De Leon G. The therapeutic community: theory, model, and method. New
York: Springer Pub; 2000.
Publisher’s Note 20. United Nations Office on Drugs and Crime. World drug report 2014
Springer Nature remains neutral with regard to jurisdictional claims in published
[Internet]. 2014 [cited 2015 Jul 7]. Available from: http://www.unodc.org/
maps and institutional affiliations.
documents/wdr2014/World_Drug_Report_2014_web.pdf
21. Johnson KW, Young L, Shamblen S, Suresh G, Browne T, Chookhare KW.
Author details
1 Evaluation of the therapeutic community treatment model in Thailand:
Department of Clinical Epidemiology and Biostatistics, Hospital Universitario
policy implications for compulsory and prison-based treatment. Subst Use
San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia. 2School of
Misuse. 2012;47:889–909.
Medicine, Pontificia Universidad Javeriana, Bogota, Colombia. 3Unity of
22. Fernández-Montalvo J, López-Goñi JJ, Illescas C, Landa N, Lorea I. Evaluation
Epidemiological Studies in Mental Health, Psychology Faculty, National
of a therapeutic community treatment program: a long-term follow-up
University of Cordoba, Cordoba, Argentina. 4Department of Psychiatry,
study in Spain. Subst. Use Misuse. 2008;43:1362–77.
Federal University of São Paulo (UNIFESP), São Paulo, Brazil. 5Consejero
23. Sadir N, Shojaei M, Moadab K, Abbasi R, Bahrampour A, Nakhaee N.
Terapéutico State Council Against Addictions, Guadalajara, Jalisco, Mexico.
6 Outcome evaluation of therapeutic community model in iran. Int J Health
Polymetrix, Cabo San Lucas, Jalisco, Mexico. 7Universidad Peruana Cayetano
Policy Manag. 2013;1:131–5.
Heredia, Lima, Perú. 8National Institute of Public Health, Lima, Peru.
24. Darke S, Campbell G, Popple G. Retention, early dropout and treatment
completion among therapeutic community admissions. Drug Alcohol Rev.
Received: 14 May 2017 Accepted: 16 October 2017
2012;31:64–71.
25. Ministerio de Justicia y del Derecho - Observatorio de Drogas de Colombia,
Ministerio, de Salud y Protección Social. Estudio Nacional de Consumo de
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