Addiction Professional By Peter Provet, Ph.D.
The therapeutic community (TC) model of substance abuse treatment is at an important crossroad in its evolution. Approximately 45 years old, this self-help model was developed to treat single, adult heroin addicts in tightly controlled, long-term residential treatment settings. Only recently – perhaps over the past five to 10 years – have there been significant strides in adapting this proven model to a broader range of treatment populations.
This article describes some of the enhancements therapeutic communities have forged to meet the needs of a broader population of substance abusers, including women and children, adolescents, the mentally ill and senior citizens. It is the fundamental premise of this article that such efforts are essential if the therapeutic community model is to stay relevant and achieve a broader acceptance and applicability in the overall field of drug and alcohol abuse treatment.
The self-help model, where one addict supports and confronts another, was born in part out of a rebellion against the dominant medical approaches of the day, which reinforced a more passive, “patient” role for the drug abuser. Loud, direct and powerful confrontation of the addict’s negative behaviors and attitudes was the cornerstone of this new approach. A system of behavioral intervention quickly evolved where both reinforcement and punishment were used to shape behavior within a hierarchical work structure.
The TC recognizes drug use as the symptom, and the person’s character flaws – negative behaviors and attitudes – as the fundamental problem. In response, the public role-modeling of positive behavior becomes the central therapeutic vehicle. Positive peer pressure is recognized as an antidote to the negative pressure that dominated the addict’s former social world. The concepts of personal responsibility and accountability, empathy, introspection, respect for authority, work ethic, and a sense of social compassion and justice were woven into the community’s social fabric.
The residential therapeutic community as we know it today, with its average length of stay of 12 to 18 months, serves as a “safe-enough” environment for troubled individuals to experiment in role-modeling new, more adaptive behaviors and attitudes. Insecurities and incompetencies, and their attendant low self-esteem, are slowly resolved in a treatment regimen that is more a corrective, rather than an intellectual, experience.
Contrary to its reputation, the TC is a flexible and accommodating treatment model for all categories of substance abusers. Many TCs have, for example, developed high-quality treatment programs for extraordinarily diverse populations such as adolescents, mothers and children, and seniors. Others provide TC treatment for mentally ill chemical abusers, a population that has gained significant interest and attention, driven by a growing recognition and acceptance of psychiatric disorder within addicted populations.
By narrowly defining the TC model, we run the risk of limiting the evolution of this potent treatment approach or, worse, of failing to provide services to some of society’s most needy and troubled substance abusers.
At its core, the TC reverses ingrained dysfunctional behavior within a social context and delivers an impressive return on society’s investment. Its efficacy is widely demonstrated in national research studies (National Institute on Drug Abuse (2000), Principles of Drug Addiction treatment: A Research-Based Guide), and the benefits of treatment include a catalogue of positive treatment outcomes, from the most obvious reduction in drug use to lesser-known measures such as the attainment of full-time employment, reduced criminal activity, and reunited families (NIDA (2002), Research Report Series: Therapeutic Community).
The Enhanced Therapeutic Community
As developed and practiced at Odyssey House, the Enhanced Therapeutic Community (ETC) maintains the fundamental model of the TC (De Leon (2000), The Therapeutic Community: Theory, Model, and Method) while systematically incorporating other clinical services to meet the needs of any given treatment population. Rather than perceiving such integration as a threat to the core model, the Enhanced Therapeutic Community is strengthened by it. Medical, vocational, and school services are no longer seen as “ancillary” or “additional.” Rather, they are viewed as fundamental to the model itself, and as a result, essential to the change process which the model promotes.
For an ETC to achieve maximum effectiveness, three fundamental questions must be fully addressed regarding a specific treatment population:
1. What, if any, elements of the standardized TC treatment protocol must be altered, augmented, decreased, or withdrawn completely?
2. What new, additional services must be incorporated into the structure and daily functioning of the TC to address otherwise unmet clinical needs?
3. What is the prescribed length of treatment?
Individual client needs dictate the services provided within the ETC. The model is adapted to the client, rather than vice versa. This is a fundamental shift in traditional TC methodology that maintains the fixed nature of the model.
Drug abuse has slowly become recognized as a disorder impacting the family-of-origin in both direct and indirect ways. Some of the greatest clinical challenges demanded of the TC are how to address the multifaceted needs of families, in particular the needs of mothers and their young children.
The Odyssey House Family Center, a 170-bed treatment program, is one example of an ETC. Different to some other stand-alone women and children treatment centers, this program is housed in the same facilities as those for the Odyssey House single adult population and its program for seniors (drug abusers 55 and older). Each parent – the overwhelming majority are women – is able to bring two children under the age of five with her into treatment.
As the mother participates in the general therapeutic community regimen, her children are cared for in day care or preschool facilities by certified teachers, occupational therapists, physical therapists and pediatric nurses who address the youngsters’ emotional, social, medical and cognitive developmental needs.
Every day, young mothers in treatment for chronic substance abuse are encouraged to develop new ways of interacting with their children that foster a deeper, consistent bond between parent and child. For the families in treatment, the normal bonding that takes place between parent and infant was disrupted by the mothers’ drug use. But in our residential treatment environment where the mother and child live together, and therefore the opportunity for physical connection is provided, our experience shows that in cases where the emotional attachment is interrupted by substance abuse, the mother and child respond to the therapeutic and peer support and begin to develop a secure, healthy and strong relationship.
The power of the Enhanced Therapeutic Community to support the mother through her parenting experience is magnified by the complexity of available peer interactions. For example, at one Family Center an intergenerational drug treatment approach is practiced within a 333-bed facility. Four generations interact on a daily basis, growing and learning from one another.
Newborns, infants, toddlers and pre-school children grow and learn in structured child-care programs while their mothers engage in rigorous drug treatment; other, single adults participate alongside these parents; and residents in our ElderCare program provide occasional child support and parenting/grandparenting advice.
This peer-driven Enhanced Therapeutic Community allows for myriad forms of learning for the mother. Older, single adults regularly serve as parental role models. ElderCare residents (some as old as 75) serve as grandparent role models to the young mothers and great-grandparent role models to their children. For each – child, young mother, middle-aged adult and senior citizen – therapeutic benefits accrue from a multitude of empathic interactions, many of which were never experienced during an active drug lifestyle.
In structured day care settings, with staff present to encourage positive engagement skills and empathic communication, inexperienced parents are also consistently taught appropriate limit-setting and discipline techniques to use with their children. True to core TC methods of using group interaction to effect personal change, clinical guidance is primarily offered within a group setting where women support and learn from one another.
But providing families with private space is also important. Each small family has a bedroom suite within each facility to assist mothers in developing a separate family identity, while still being able to connect with the larger community. This is achieved through mainstreaming Family Center residents into the overall TC schedule of each facility, while accommodating enhanced services such as parenting skills workshops, domestic violence seminars and child development classes. Whereas a traditional TC may perceive this as “special” treatment, the ETC simply recognizes it as essential.
One of several examples of such a programming priority is the parenting skills workshop. Once a week for an hour and a half, over the course of 10 weeks, mothers participate in an experiential workshop on parenting issues run by a social worker. Each seminar addresses a fundamental concept of parenting – such as discipline, the “terrible twos,” and empathy. Each topic inevitably raises memories for the mothers of their own childhoods and connections are made between their own, often painful, childhood experiences and present-day challenges of parenting.
One of the overarching functions of this clinical service is the prevention of intergenerational child abuse. Many of the mothers in this program have histories of early physical, sexual and emotional abuse, which too easily can be transferred to the next generation unless proactive and intensive interventions are forged. And where better to address these issues than in the safe environment of a residential community with peer identification and professional oversight?
Pertaining to the second question noted above regarding the ETC, this clinical intervention most clearly represents an additional, though necessary, service for mothers and children.
As mothers in the Family Center program participate in the core fabric of the therapeutic community, job functions and their attendant peer interactions are central to therapeutic progress. How peers and staff alike administer confrontation and negative consequences to the mothers for programmatic infractions is partly dictated by their children’s physical, if not emotional, proximity. Confrontation must be a more private experience to protect the child’s relationship to his mother and to foster his evolving conception of her as the central authority figure. Once again, when carefully and consistently implemented, this approach strengthens the power and generalizability of the TC, rather than diluting it.
The Family Center program is representative of one Enhanced Therapeutic Community; there are many others, including programs for adolescents, the mentally ill, homeless persons and seniors.
Adolescents present distinct treatment challenges to the traditional TC model, and counselors must consider what elements of standard treatment might need to be altered to maximize therapeutic efficacy. One TC technique that most providers agree that it is best not to utilize is the “haircut.” This is a loud, public, verbal reprimand delivered by a staff member to a resident who has broken a fundamental community rule and has been unresponsive to other clinical interventions.
While often effective with adult clients, this strategy can backfire with adolescents. For the adolescent the experience is embarrassing, if not humiliating, and may trigger an intense hostile response partly due to recent historical experiences of a similar nature within his or her family system. An adult’s loud and public reprimand of an adolescent in front of the youngster’s peers is now known to be of questionable therapeutic benefit.
What additional services may be integrated into the TC regimen to meet adolescents’ needs? The most obvious services are a formal high school program and a comprehensive family therapy program. How these services, and their representative staff, are integrated into the core program is, however, critical. If, for example, they are treated as “ancillary,” a division is created and the functions are relegated to a secondary status, resulting in an undermining of the ETC mission of valuing all program elements and of promoting a seamless service delivery system.
As mentioned earlier, one of the fundamental questions asked of treatment professionals is how long is an appropriate length of stay. Through much of its history, the TC has been a long-term treatment regimen, typically 12 months or longer. With such a fixed length of stay, the addict fits into the program’s time structure, not vice versa.
But adolescents have greatly varying needs. Some juveniles have supportive families, moderate to high levels of ego strength, and strong academic potential. Others come from dysfunctional families, have histories of significant neglect and/or abuse, and lack fundamental cognitive or emotional skills. The ETC premise is that individual diagnostic assessments should dictate length of stay, not an arbitrary “one size fits all” treatment protocol.
The therapeutic community model must continue to embrace more professional disciplines, integrate a wide range of clinical techniques, and adapt more individualized treatment planning processes while maintaining the core methods and values central to its well-documented efficacy. The range of populations treated at many TCs is testament to the strength – and elasticity – of the core model.
The TC holds great promise to reach broader segments of society’s most troubled and disenfranchised individuals, as it evolves into the inclusive clinical vision of the Enhanced Therapeutic Community.