Therapeutic Community Elements:

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Therapeutic Community Elements

• Theory,

and Method

• Model,

George De Leon Center for Therapeutic Community
Research at NDRI, Inc. New York City
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Four Interrelated Views
The Therapeutic Community Perspective
View of Disorder ? Drug abuse is a disorder
of the whole person involving some or all the
areas of functioning.

• Cognitive, behavioral, emotional, medical, social
  and spiritual problems
• Physical dependency must be seen within the
  context of the individuals psychological status
  and life style
• Problem is the person, not the drug

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The Therapeutic Community Perspective contd

• View of the Person ?
• Rather than drug use patterns, individuals are
  distinguished along dimensions of psychological
  dysfunction and social deficits.

• Some shared characteristics
• Poor tolerance for frustration, discomfort, delay
  of gratification
• Low self-esteem
• Problems with authority
• Problems with responsibility
• Poor impulse control
• Unrealistic
• Difficulty coping with feelings
• Dishonesty, manipulation, self-deception
• Guilt (self, others, community)
• Deficits (reading, writing, attention,
  communication)

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The Therapeutic Community Perspective contd

• View of Recovery ?
• The goals of treatment are global changes in
  lifestyle and identity.

• Some assumptions about recovery
• Recovery is developmental learning
• Self-help and mutual self-help
• Motivation
• Social learning
• Treatment is an episode in the recovery process

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The Therapeutic Community Perspective contd

• View of Right Living ?
• Certain precepts, beliefs and values as
  essential to self-help recovery, social learning,
  personal growth and healthy living.

• Some examples
• Truth/Honesty
• Here and Now
• Personal Responsibility for Destiny
• Social Responsibility ("Brother's/Sister's
  Keeper")
• Moral Code Concerning Right and Wrong Behavior
• Work ethic
• Inner Person is "Good", but Behavior Can be "Bad"

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The Therapeutic Community Perspective contd

• Change is the only certainty
• Learning to learn
• Economic self-reliance
• Community involvement
• Good citizenry

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Components of a Generic TC Program

• Community separateness
• A community environment
• Community activities
• Staff roles and functions
• Peers as role models
• A structured day
• Work as therapy and education
• Phase format
• TC concepts
• Peer encounter groups
• Awareness training
• Emotional growth training
• Planned duration of treatment
• Continuity of care

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Community as Method Four Components
Community as method is described in terms of four
interrelated components

• Its context of peer and staff relationships, and
  the daily regimen of activities
• Its expectations for individuals participation
• Its assessment of the individuals progress in
  meeting these expectations
• Its responses to individuals meeting or not
  meeting expectations

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Community as Method
I. Community Context Component ? Context
consists of the elements of the community - the
program structure, daily regimen of activities,
and social relationships which are the tools to
be used for self-change. The fundamental
assumption of community as method is that
individuals obtain maximum therapeutic and
educational impact when they participate fully as
members of the community that is, when they use
the context, the community elements, as tools for
self-change,

• The groups
• Meetings
• Work
• Seminars
• Relationships
• Multiple social roles

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Community as Method
II. Community Expectations Component ?
These are the standards set by the membership
concerning the goals of participation and use of
the community as tools for self-change. These
expectations are described in terms of the
following

• Performance
• Responsibility
• Self-examination
• Autonomy

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Community as Method
III. Community Assessments Component ?
These are various strategies for evaluating
whether and how residents are meeting
expectations. These typically consist of the
following

• Exposure
• Teaching
• Testing
• Challenging

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Community as Method
IV. Community Responses Component ?
These are the communitys positive and negative
reactions to its assessment of the individuals
efforts in meeting expectations. These reactions
may be -

• Supportive
• Affirmative
• Critical
• or
• Corrective Actions
• Sanctions/privileges

They are implemented as various consequences to
promote the individuals participation in and use
of the community.
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Classification of TC Methods/Interventions

• Therapeutic/educative/Groups
• Community and clinical management/Priveleges,
  Sanctions/Verbal correctives and affirmations
• Community enhancement/meetings
• Additional activities and interventions

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Behavioral Dimensions Of Change in the TC

• Community member
• Socialization
• Developmental
• Psychological

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Domains of Progress in Treatment
Developmental Dimension 1. Maturity
(self-regulation, social management) 2.
Responsibility (accountability, meeting
obligation) 3. Values (integrity, right living)  
Psychological Dimension 8. Cognitive skills
(awareness, judgment, insight, reality testing,
decision making and problem-solving skills) 9.
Emotional skills (communication and management
of feeling states) 10. Self-esteem/self-efficacy
(sense of well-being)
Socialization Dimension 4. Drug/criminal
lifestyle (social deviancy) 5. Maintains images
(social vs. anti-social lifestyle) 6. Work
attitude (attitude appropriate for the work
world) 7. Social skills (ability to relate to
people)
Community Member Dimension 11. Understands
program rules, philosophy, and structure 12. Commu
nity engagement and participation 13. Attachment,
investment, and stake in the community 14. Role
model (lives by example, teaching others)
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Essential Experiences in the TC Process

• A. Emotional Healing
• Nurturance
• Physical safety
• Psychological safety

• C. Subjective Learning
• Objective and subjective outcomes
• Self-evaluative feelings, judgment, perceptions
• Self-rejection
• Self-efficacy
• Self-esteem

• B. Social Relationships and Caring
• Identification
• Empathy
• Bonding

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Essential Perceptions in the TC Process

• A. Perceptions Related to Treatment
• Circumstances
• Motivation
• Readiness
• Suitability

• B. Perceptions Related to Progress and Change
• Perceptual contrast (behavioral, cognitive, and
  emotional differences)
• Self Change (self-care, self-control,
  self-management, self-understanding,
  self-concept)
• Identity Change (social images and personal
  awareness social and self efficacy)

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Behavioral and Social Learning Principles in the
TC Process

• Efficacy training (overcoming past failures,
  completion, new skills)
• Trial and error learning (failure is not trying,
  errors and internalization)
• Positive and negative reinforcement (e.g.,
  privileges, sanctions, community status)
• Social role training (role model, job roles,
  community roles)
• Vicarious learning (identification, imitation)
• Community as trainer
• - all learning naturalistically
  mediated

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Stages of Participation

• Engagement (limited participation)
• Immersion (totality of involvement in the
  community)
• Emergence parallel participation in the peer
  community and the outside world
• If you participate, then you will
  change

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Program Stages of Change in the TC Process

Stage 1 Induction Stage 2 -- Primary
Treatment Stage 3 Re-Entry
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Treatment Stages of Internalization in the TC
Process

• Compliance
• Conformity
• Commitment
• Integration

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A Model of Treatment Process in a Therapeutic
Community
Stability and Longevity of Desired Outcomes