This chapter presents the formulation of the therapeutic community (TC) as theory, model, and method. The TC has proven to be a powerful treatment approach for substance abuse and related problems in living. The TC is fundamentally a self-help approach, evolved primarily outside of mainstream psychiatry, psychology, and medicine. The TC’s basic approach of treating the whole person through the use of the peer community, which was initially developed to address substance abuse, has been amplified with a variety of additional services related to family, education, vocational training, and medical and mental health. The evolution of the TC reveals the vigor, resourcefulness, and flexibility of the TC modality to expand and adapt to change. The sophistication of the TC is evident in the fact that Therapeutic Communities of America (TCA) has established criteria and procedures for evaluating counselors and certifying their competency.
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In the therapeutic community (TC), program stages are prescribed points of expected change. Individual status can be described in terms of typical profiles at various points in the plan of the program. This chapter provides a description of the program stages as the main structural component of the TC model, specifically designed to facilitate the change process. In traditional long-term residential TCs, there are three main program stages, induction, primary treatment, and re-entry, consisting of several phases or substages. These stages are described in terms of main goals, stage-specific activities, and typical outcomes. Individuals who complete all stages of the planned duration of treatment are candidates for program graduation. Aftercare plans are a special activity of the late re-entry phase of the program. Each stage-phase marks signify where individuals are in their socialization and psychological growth.
The quintessential element of the therapeutic community (TC) approach is community. It is the element of community that distinguishes the TC from all other treatment or rehabilitative approaches to substance abuse and related disorders. TCs differ profoundly from other communities in their rationale and purpose. This chapter discusses the general characteristics of community as a treatment approach: its relationship to the TC perspective, its healing and learning properties, and its social and cultural features. It translates this approach into a specific method the components of which are the “active ingredients” in the treatment process. Residents in TCs have been labeled as bad or rebellious kids, dangerous addicts or criminals, failures or losers, sick or crazy. The negative social labels become embedded in self-perceptions regarding their social and personal identities. The community approach fosters change in the social and personal elements of identity.
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.
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.
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.
In the therapeutic community (TC), the therapeutic and educational component that focuses specifically on the individual consists of the various forms of group process. The groups that are TC-oriented, such as encounters, probes, and marathons, retain distinctive self-help elements of the TC approach. This chapter provides an overview of general elements and forms of group process in the TC. Conventional psychotherapy and group therapy have not been particularly effective with substance abusers entering TCs for various reasons. Group tools are certain strategies of verbal and nonverbal interchange that are employed by participants to facilitate individual change in group process. There are two main classes of group process strategies: provocative tools and evocative tools. Provocative tools, hostility or anger, engrossment, and ridicule or humor, are most pointedly used to penetrate denial and break down deviant coping strategies such as lying.
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.