1. Background
As the most populated Persian Gulf country, Iran has a developed therapeutic community program (TCP) for the treatment of illicit drug users (1). The therapeutic community program in Iran are drug-free environments which individuals with drug use problems live together in an organized and voluntary way to promote change toward recovery from illicit drug use and reinsertion in society. This program in Iran originates in the US TCP and benefits from family counselling, peer group meetings and cognitive-behavioural skills for craving management and relapse prevention (1).
Most TC centers are directed by rebirth society, a well-known nongovernmental organization (NGO). In fact, Rebirth provides drug treatment services to 100,000 clients per year under the supervision of the ministry of health. In 2005, rebirth society received the United Nations civil award as the best NGO active in drug demand reduction in the world (2).
There are a few studies of TCP evaluation in Iran. A three-year treatment outcome evaluation of 43 male clients at TC in Tehran indicated that the mean scores of drug and alcohol use, quality of social/family relationships, psychiatric status and medical status were improved while in treatment. Scores for employment status indicated a reduction demonstrating an improvement in this domain. The study indicated that the relationships with others were significantly improved following receiving TCP (3). A seven-year TC outcome evaluation in Kerman had 378 male participants. Overall, 240 of them completed the 14 weeks of treatment. At the end of the sixth year follow-up, 22% of the participants were in drug abstinence. Physical and mental health in clients who stopped drug use were significantly improved than those who did not (4).
2. Objectives
Since 2001, women-only TCP were opened in some cities of Iran such as Tehran and Karaj. This is the only women-only TCP in Western Asia (1). However, to the best of our knowledge, there is no study of drug-dependent women on TCP and their needs while in treatment in Iran. The current study aimed to explore the treatment needs of a group of Persian women on TCP while in treatment.
3. Materials and Methods
3.1. Study Settings and Participants
A qualitative study was designed and conducted in March 2011. The study sites included Chitgar, Shahriyar and Hesarak centers in Tehran city, Iran and Shahr-e-Ghods center in Karaj city. Qualitative methodology was selected as the main method of conducting the study because of no research about women on TCP has been conducted in Iran. An interview guide was developed to facilitate qualitative interviews.
Women were reached for study recruitment by four well-trained clinical psychologists who talked with women about the possibility of their participation in the study. Women were eligible to enter the study if they were at least 18 years of age and reported no drug withdrawal symptoms at the time of recruitment. Women were excluded if they reported severe psychiatric and/or physical problems which were likely to act as barriers to successful interviewing.
The study was approved and funded by substance abuse and dependence research center, university of social welfare and rehabilitation sciences in Tehran. Participation was confidential and voluntary.
3.2. Study Procedure
The interviewers explained the study procedure and obtained informed consent prior to the interviews. Five women at each center voluntarily participated in the study. Sample recruitment continued until we reached data saturation. Semi-structured qualitative interviews and focus group discussions were conducted with 20 women and nine key experts. Women were remunerated with small gifts following the completion of their interview.
The interviews were conducted to explore the treatment needs of women in treatment. Women were individually interviewed and key experts were interviewed in three focus group discussions at the centers. Interviews were audio-recorded and averaged 65 minutes in length. Interviews were transcribed verbatim and checked for accuracy by one of the interviewers. The key experts included psychologists, social workers, center managers and doctors who worked with the women.
3.3. Data Analysis and Quality Control
Interview transcripts were imported into Atlas-ti software to facilitate coding. We coded transcripts using an inductive and iterative process (5). The research team met regularly to discuss emerging themes. The lead co-author recoded the data following the establishment of the final themes to enhance reliability and validity (5). Specifically, we sought to illuminate how the treatment needs in treatment were perceived. The lead author consulted with the center managers prior to the launch of this study and drew upon their input to inform the study design. To determine validity in data collection, we also presented our findings to the directors in the preliminary stages of analysis and following the completion of this manuscript as member-checking (6). They provided strong feedback during the initial presentation and confirmed that our themes significantly reflected their experiences.
4. Results
4.1. Baseline Data
The median age of the women was 32 years. The median year of education was nine years. Most women lived with their families and were unemployed. Most of them were poly users of heroin and methamphetamine before treatment entry. The main route of illicit drug use was smoking (Table 1).
Table 1.Baseline Characteristics of the Women (n = 20)
| Characteristics | Frequency |
|---|---|
| Age range, y | 23 - 49 |
| Median age, y | 32 |
| Schooling range, y) | 6 - 14 |
| Median schooling, y | 9 |
| Living conditions (with) | |
| Family | 12 |
| Homeless | 4 |
| Relatives | 2 |
| Friends | 2 |
| Housing | |
| Rented housing | 14 |
| Homeless | 3 |
| Own apartment | 3 |
| Employment | |
| Unemployed | 14 |
| Homemaker | 5 |
| Employed | 1 |
| Main type of drug use | |
| Low purity heroin and impure methamphetamine | 16 |
| Opium and impure methamphetamine | 2 |
| Opium | 2 |
| Main route of drug use | |
| Smoking | 19 |
| Smoking and ingestion | 1 |
| Median year of illicit drug initiation, y | 17 |
| Median year of drug dependence, y | 22 |
| Lifetime drug treatment | 6 |
4.2. Treatment Needs on TCP
4.2.1. Continued Professional Staff Training
A theme that gradually emerged from the narratives was the necessity of continued professional staff training and using the latest international TCP guidelines.
A psychologist reported:
“…We should train in the latest international TCP guidelines and every three years, we should know the latest changes in these guidelines…Our staff members need intensive professional training… We should update their training every year…”
A drug-dependent woman reported:
“…The staff members are fine here but they need to have professional training to direct this center better… Staff members should train to screen and admit those women who benefit from the treatment.”
4.2.2. Considering Treatment Needs of Special Female Groups
Some women such as pregnant women, homeless women, sex workers, HIV-positive women, women with the dual diagnosis of illicit drug use and psychiatric disorders and/or criminal histories were reported as groups with special treatment needs whom would be likely not to benefit from TCP. Interviewees frequently reported the necessity of either establishing special TC centers or the provision of specific drug treatment programs for these groups.
A psychiatrist reported:
“…We see this treatment isn’t good for some women such as female sex workers and homeless women. Specific TC centers should be established for these groups and they should receive specific drug education and treatment…”
A drug-dependent woman reported:
“…Female sex workers and homeless women should have special treatments on TCP. For example; they should receive treatment to control sex addiction and avoid drug dealers who want sex exchange for drugs…”
4.2.3. Extended Treatment Duration with Special Services
Participant narratives underscored how women required free continued treatment with childcare services and multiple recreational facilities during their residence at the centers. The analysis of participant accounts highlighted how most women required remaining on TCP as long as they wanted. Some women had small children and needed free childcare services while in treatment.
A manager reported:
“…Drug-addicted women need no limitation for treatment residence. They need to enjoy a free treatment and remain in treatment as long as they need. But, free treatment isn’t enough…Childcare services, internet and computer games, more recreational facilities and play rooms should be provided at the centers...”
A woman reported:
“…I’m worried about my two children. They’re home with their daddy. I wish some childcare facilities here. I watch TV and chat with women at the center. I help with cooking, cleaning and praying at the center. There are some sports facilities but I want some internet works, a small game room or some small classes for knitting at the center.…”
4.2.4. Family Support and Education
Participant narratives underscored how women required family support and education during their residence at the centers. The analysis of participant accounts highlighted how women required financial and emotional support from their families to continue treatment. Furthermore, women reported how they needed to learn behaving with their families.
A social worker reported:
“…Our families need so much patience, emotional and financial support and education during our treatment…Our families don’t know how to behave with us…We need to learn how to behave with our families…”
A woman reported:
“…Most women feel depressed because of family conflicts, no emotional and financial support and long years of drug addiction…Family should be educated to help us with drug rehabilitation while in treatment…”
5. Discussion
In recent years, illicit drug use among women has been considered as a health concern in Iran (7, 8). Recently, women-only drug treatment programs have been provided in Iran as the first practice in Western Asia (8). Women-only drug treatment programs have emerged in response to the multidimensional profile of problems that women display upon admission to gender-mixed drug treatment centers (9). Research studies in the USA have indicated that women and men differ in drug use aetiology, disease progression, and access to treatment for illicit drug use. Women-only drug treatment has been proposed as one way to meet women’s distinctive needs and reduce their barriers to receiving and remaining in treatment (10). The extent to which treatment programs vary in women-only drug use treatment settings versus mixed-gender drug use treatment settings in real-world deserves more research.
Importantly, our findings show the necessity of professional staff training and using updated treatment guidelines. The provision of updated staff training and training in international TCP guidelines are among the most essentials factors which may contribute to treatment compliance among drug-dependent women on TCP. This is of particular importance as women treated with TCP increasingly may require multiple treatment programs to manage illicit drug use problem. A study at a TC center in the USA indicated that staff training and the provision of professional TCP increased treatment retention and outcomes among clients (11). More studies are suggested in Iran.
The study results also highlighted the role of considering treatment needs of special female groups such as sex workers and homeless women. Special groups of women may have special treatment needs which may not be addressed using TCP only. A study in Iran indicated that some groups of women with illicit drug use problem such as sex workers need special treatment needs (12). More studies are suggested.
Strategies that account for drug treatment compliance among women were primarily emphasized particularly in light of the provision of free extended treatment stay, childcare services and recreational facilities while in treatment. Most participants emphasized the necessity to remain in treatment as long as they required. Some of them had small children and needed free childcare services. The centers were in need of recreational facilities such as internet, computer and game rooms. But, treatment stay was short and the required facilities were not available. In light of concerns regarding treatment, formally integrating these adjunct requirements into TCP for women and orienting it toward enhancing treatment retention and positive treatment outcomes would likely allow for sufficient oversight to consider these issues. A study of drug-dependent women at drop in centers in Isfahan and Shiraz cities indicated that prolonged stay in treatment and the provision of recreational facilities were frequently asked by women as important component of drug treatment needs (13). A study indicated that cocaine-dependent women who had access to childcare services on TCP were more likely to stay in treatment compared with women who did not have access to childcare services (14). A study of 300 substance users at a TC center in Dallas, USA indicated that behavior modification, updated educational services, medical/psychiatric facilities and specialized adjunct services such as childcare services facilitated long-term recovery among illicit drug users (15). This important study finding should be considered by health policy makers in the effective provision of women-only TCP in Iran.
Family support and education were last reported treatment needs among women. The role of family in the effective provision of drug treatment has been confirmed in the literature (1, 8). The role of family support and education in the effective provision of TCP for women should be investigated in Iran.
5.1. Conclusions
The current study confirmed the roles of some factors which were reported as the treatment needs of a group of drug-dependent women on TCP. Such factors should be considered in designing and implementing effective TCP for women in Iran.
5.2. Limitations and Suggestions
As the first study in Western Asia especially the Persian Gulf region, the current study was limited to women on TCP in Tehran and Karaj cities. Therefore, the findings may not be generalizable to other women in other parts of the country. Data were collected by self-report which are subject to underreporting or bias. However, participation was voluntary and confidential. More studies are suggested.
