Work is one of the most distinctive components of the therapeutic community (TC) treatment model. Indeed, the telling mark of the TC social environment is the vibrancy of its work activities. Work in the TC is a fundamental activity used to mediate socialization, self-help recovery, and right living. This chapter describes how work mediates essential educational, therapeutic, and community goals. For disadvantaged, antisocial, or nonhabilitated substance abusers, many of whom have few work skills, social identity and self-esteem are first acquired through participation in the work structure of the TC. Work in the TC addresses characteristics of the person and the disorder. These characteristics can be classified into related categories: personal habits, work habits, work relations, self-management, and work value. Job functions are utilized in three main ways: for skills training and education, for therapeutic change, and to enhance the peer community.
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Residents in the therapeutic community (TC) engage in a variety of interpersonal roles and relationships both within and outside of the program. Friendships and attachments, romantic or sexual, “naturally” emerge within the peer community and are profoundly affected by the insistent intimacy of the TC community life. This chapter examines how these interpersonal relationships are utilized to transmit community teachings on right living and recovery. The poor quality of past friendships and romantic attachments has been implicated in the drug problems of substance abusers in general. Among residents in TCs, the relationship problems that most commonly surface are related to sexuality, interpersonal fears, and lack of relationship skills and values. Of special importance to the individual and the community, however, are three main types of relationships: sexual relationships, romantic relationships, and friendships. Contemporary TCs have changed their tolerance levels toward greater acceptance of homosexuality.
A theoretical framework of the therapeutic community (TC) grounded in clinical and research experience can maintain the unique identity of the TC and the fidelity of its wider applications. This chapter illustrates several broad initiatives: generic TC model, general guidelines for adapting and modifying the TC for special settings, special populations, and funding limits; the codification of principles and practices of the TC into explicit standards to maintain the integrity of the program model and method, training and technical assistance, and research agenda. Staffing compositions have changed to reflect a mix of traditional professionals; correctional, mental health, medical, educational, family, and child care specialists; social workers; and case managers to serve along with the experientially trained TC professionals. The evolution of the contemporary TC for addictions over the past 30 years may be characterized as a movement from the marginal to the mainstream of substance abuse treatment and human services.
In the therapeutic community (TC), surveillance means supervision and management of the orderliness and safety of the physical environment, as well as the health and conduct of the social environment. This chapter describes the main facility-wide surveillance activities of the general inspections (GI), the house run, and urine testing, actions implemented in the management of the community. The GI is a useful community and clinical management activity. The house run is the main system of surveillance in the TC. In terms of management goals, house runs permit early detection of potentially larger problems such as those related to fire, sanitation, and security. However, its fundamental clinical purpose is to assess the status of individuals in terms of self-care, self-management, and their relationship to the community. The main urine test procedures used by most TCs are unannounced random urine screens and incident-related testing procedures.
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.
At the core of the change process in the therapeutic community (TC) is the relationship between the individual and the community. Internalization is a familiar psychodynamic concept connoting learning that involves “taking in” the behavior and teachings of others. In the TC, internalization is evident when new learning becomes a “natural” part of the individual’s repertoire. In the TC internalization is inferred from patterns of behavioral, experiential, and perceptual change occurring over time. These may be described in terms of several broad characteristics: cognitive dissonance and behavioral conflict, generalization, learning to learn, and confirmatory experiences. The course of internalization can be characterized as a gradient that depicts changing levels or stages of internalization. Four stages refer to changes during treatment, compliance, conformity, commitment to program, and commitment to self. A change in identity is the distinctive marker of the integration stage.
Encounter group is a profoundly significant component of the therapeutic community (TC) approach, illustrating by example some of the TC’s basic teachings: compassion and responsible concern, the necessity for confronting reality, absolute honesty, and self-awareness as the essential first step in personal change. The encounter group is pre-eminently a verbal forum employing everyday personal and social vernacular. All encounter groups in the TC are similar in their preparation, structure, and process. An encounter unfolds as a process characterized in terms of four phases: the confrontation, the conversation, the closure, and the socializing phase. Ideally, each encounter accomplishes its general purpose of strengthening group cohesion and its goals for specific individuals. Depending upon its purpose or group composition, the encounter can be modified in intensity and format and the extent of staff involvement as facilitators.
In the therapeutic community (TC), peers are the primary change agents. In their varied social roles and interpersonal relationships, residents are the mediators of the socialization and therapeutic process. This chapter details how peer roles and relationships are utilized by the community to facilitate the goals of socialization and psychological change. The socialization history of serious substance abusers is marked by negative peer influences. Functional roles in the TC are those involving performance demands, prescribed skills and attitudes, and defined relationships with others. Three prominent community member roles are peers as managers, as siblings, and as role models. A defining element of the TC model is the use of peer roles for social learning. The chapter describes how the various community and functional roles in the social organizations are utilized by peers to change themselves and others and how socially conditioned race-ethnic and gender roles and issues are addressed.
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.
This chapter describes the various roles and functions of the treatment program or clinical management staff in the residential facility. It characterizes the roles of support staff and agency personnel. Teachers, physicians, nurses, psychologists, social workers, lawyers, and accountants in the TC ply their professions in the usual way. The relationship between staff and peer roles is rooted in the evolution of the Therapeutic Community (TC). In the TC approach, the role of staff is complex and can be contrasted with that of mental health and human service providers in other settings. An array of staff activities underscores the distinctively humanistic focus of the TC. The chapter describes how primary clinical staff in the treatment program supervise the daily activities of the peer community through their interrelated roles of facilitator, counselor, community manager, and rational authority. Other staff provide educational, vocational, legal, medical, and facility support services.