The idea of the therapeutic community (TC) recurs throughout history implemented in different incarnations. In its contemporary form, two major variants of the TC have emerged. One, in social psychiatry, consists of innovative units and wards designed for the psychological treatment and management of socially deviant psychiatric patients within mental hospital settings. In the other form, TCs have taken are as community-based residential treatment programs for addicts and alcoholics. This chapter explores the sources and evolution of these communities to illustrate how they contribute to the theoretical framework of the TC. It describes the direct and indirect influences shaping the essential elements of the modern TC. The early religious influences on the Oxford group and Alcoholics Anonymous (AA) reappear as elements of the modern TC. The search for an “essential TC” reveals a universal idea recurring in various forms throughout history: that of healing, teaching, support, and guidance through community.
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The therapeutic community (TC) is a culture of change. All of the activities, social roles, interpersonal interactions, and community teachings focus upon the theme of individual change. The perceptions that are considered to be essential to recovery are interrelated, although they can be organized into classes to clarify their contribution to the process. Perceptions related to treatment reflect the individual’s motivation, readiness, and suitability to engage in the process of change in the TC. Self-control is indicated when individuals perceive the problem as internal rather than external, as one of regulating their impulses. Perceptions of self-management of patterns of behaviors, attitudes, and feelings depend upon previously learned control of specific behaviors in various situations. Assessing and affirming individual progress is a central activity in the TC. Staff evaluations formally assess the levels of self-change, while peers and staff assess them informally.
From a social and psychological perspective the therapeutic community (TC) can be distinguished from other institutional or treatment settings in that its social environment is the treatment model. The main elements of this model, its social organization, and social relationships are utilized for a single purpose the reintegration of the individual into the larger macrosociety. The social organization of the TC model may be described in terms of four major components: program structure, systems, communication, and the daily regimen of schedule activities. In the TC, however, each component is utilized to facilitate the socialization and psychological growth of the individual members. This chapter provides an overview of these components and how they contribute to the TC treatment approach. Each of these components of the social organization reflects an understanding of the TC perspective and each is used to convey community teachings and promote self-examination and self-change.
In the therapeutic community (TC), recovery is viewed as a change in lifestyle and identity. It is a view that can be contrasted with the conventional concept of recovery in medicine, mental health, and other substance abuse treatment approaches. In the public health experience of treating opioid addiction and alcoholism, drug abuse is viewed as a chronic disease, which focuses treatment strategies and goals on improvement rather than recovery or cure. The TC view of recovery extends much beyond achieving or maintaining abstinence to encompass lifestyle and identity change. This chapter outlines this expanded view of recovery and details the goals and assumptions of the recovery process. It presents the TC view of right living, which summarizes the community teachings guiding recovery during and after treatment. The terms “habilitation” and “rehabilitation” distinguish between building or rebuilding lifestyles for different groups of substance abusers in TCs.
Therapeutic communities (TCs) are designed to enhance the residents’ experience of community within the residence. This chapter explores how the physical environment of the TC, its setting, facilities, and inner environment, can contribute to this perception and affiliation with community. Its separateness from the outside community in addition to its living spaces, furnishings, and décor are all utilized to promote affiliation, a sense of order, safety, and right living. TCs for the treatment of addiction are located in a variety of settings, which may be determined by funding sources and the external resistance to or acceptance of rehabilitation programs. Within the context of the TC perspective, privacy is considered an earned privilege based on the individual’s social and psychological growth. There are four physical features of the inner environment that instantly identify what is unique about a TC program: the front desk, the structure board, wall signs, and decorative artifacts.
This chapter presents a conceptual framework of the treatment process in the therapeutic community (TC). The essential elements of the perspective, model, and method are reformulated into the three broad components of the treatment process. First, the multiple interventions in the process consist of the program structure, the people, daily regimen of activities, and social interactions in the TC. Second, individual change is multidimensional, described in terms of objective social and psychological domains as well as subjective perceptions and experiences. Third, social and behavioral learning principles and subjective mechanisms such as critical experiences, perceptions, and internalization are integral in the process itself. The main elements of the treatment process in the TC have been described in terms of community interventions, behavioral dimensions, and the essential perceptions and experiences. All change in the TC is viewed from a behavioral orientation in terms of learning and training.
In the recovery perspective of the therapeutic community (TC), lifestyle and identity changes reflect an integration of behaviors, experiences, and perceptions. The essential experiences can be conceptualized under three broad themes: emotional healing, social relatedness and caring, and subjective learning. Emotional healing refers to moderating the various physical, psychological, and social pains that residents experience in their lives directly or indirectly relating to their substance use. The essential experiences reflecting psychological safety are blind faith and trust, and understanding and acceptance. Trust problems are prominent in the lifestyles of substance abusers. Hallmark characteristics of substance abusers in general are their lack of self-understanding and self-acceptance. Personal isolation or unhealthy attachments with others characterize the past social relationships of residents in TCs. The key social relatedness and caring experiences are identification, empathy, and bonding. In the TC, social learning unfolds as an interaction between the individual and the community.
In the therapeutic community (TC) perspective, the substance abuse disorder is not distinct from the substance abuser. A picture of dysfunction and disturbance of individuals entering treatment reflects a more fundamental disorder of the whole person. This chapter presents the TC view of the disorder in the context of current biomedical, social, and psychological understanding of chemical dependency. Overall, the picture that individuals present when entering the TC is one of health risk and social crises. In the TC perspective, drug abuse is a disorder of the whole person, affecting some or all areas of functioning. In the TC view, social and psychological factors are recognized as the primary sources of the addiction disorder. Substance abusers themselves cite a variety of reasons and circumstances as causes of their drug use. TC policy on the use of pharmacotherapy is currently undergoing modifications.