The Therapeutic Community for Drug Abuse Treatment : A Journey Yet Unfolding in the Recovery Movement





Introduction


Since we finished this chapter in 2012, there has been a notable gap in therapeutic community outcome research. Although systematic reviews of the research in recent years on the therapeutic community conclude that therapeutic communities produce positive outcomes on substance use, employment, criminality and psychological health, both interest and financial resources in support of this model have atrophied. Chief among the likely causes of this wane in interest in the therapeutic community model are funding sources that are increasingly limiting treatment duration and intensity, and the overarching concerns with promoting treatments whose effectiveness can be demonstrated in randomized controlled trials (RCTs). The random assignment of clients to treatment is ethically and practically challenging, as is the reduction of a purposefully multifaceted intervention such as the therapeutic community to a single controlled independent variable.


What studies that are marginally present seem to end by 2012 and those were of the therapeutic community in correctional settings. Even in this limited scope (i.e., prison-based treatment of substance use disorders) the therapeutic community model has given way to the pervasive dominance of evidence-based treatment practices, particularly cognitive behavioral therapy (CBT). Although many studies have supported the CBT outcomes, particularly in the management of depression and anxiety, which have had years of positive outcomes, these approaches have shown declines in effectiveness in the past few years. The looming suspicions for this reversal are the fidelity of implementation, a problem associated with all of the RCT-supported treatment practices, most of which demonstrate their outcomes under conditions that are difficult to replicate with the resource limitations with which most substance use disorder treatment programs operate.


As with the limits imposed on substance use disorder treatment in the greater community, the longer-term therapeutic community approaches in corrections have been curtailed by housing and population control measures aimed at moving inmates out as soon as they are perceived to be safe to the greater civilian community.


Is this the beginning of the end for the therapeutic community model, once heralded as a breakthrough treatment, showing ambitious and meaningful outcomes on abstinence, employment, criminality, and psychological improvement?




Origins


It is wrong to assume that there has always been a specific and widely accepted understanding of what is meant by a therapeutic community. The designation has an ancient pedigree and a historic association with diseases of appetite and the concept of mutual help. By the late 20th century, it had come to identify a specific mode of treatment for substance misuse, addiction, and other behavioral disorders based on the power of the treatment community to change attitudes and behavior through mutual help and a regimen of structured activities and expectations. This is a regimen designed to promote compassion and responsibility, foster self-awareness, enable social learning, and make possible the acquisition of social capital.


At the dawn of the Christian era, in 25 BCE, Philo Judaeus wrote,


They are called communitae therapeutrides … because they profess an art … more excellent than in general use … for medicine only heals the bodies but [these] heal the souls which are under the mastery of terrible … incurable diseases of pleasures and appetites.”


(Curiously, the term “appetitive” became a neurobehavioral declaration regarding addictive behavior in the late 20th and early 21st centuries—as supported by neuroimaging techniques that became available in the late 20th century.) Thus it appears that the struggle with uncontrolled appetite behavior was a challenge then, as it is now, and the ancients embraced an approach not unlike the therapeutic communities of today.


We can presume that Philo, writing in Alexandria early in the 1st century, was describing the early Essene communities, where according to the Qumran Community rules of order and duty, life was meant to conform to the following principles: concern for the state of our soul and our physical survival; search for meaning (transcending truths); challenge and admonish with love; be invasive—accountable to the community; public disclosure of acts, fears, hopes, guilt; public expiation for wrongs done; banishment is possible—done with concern for survival; and leadership by elders—by models.


These same principles have been present in mutual help communities from early monastic splinter groups to the much later Methodist congregations that espoused a “return to first principles” and morphed into the early Oxford movement. It may well be that combining two sets of rules—one imposing rigid moral and behavioral standards and the other promoting humanizing compassion and forgiveness—is why these principles have so often and so successfully been brought to bear on delinquent or deviant behavior, problems of social maladaptation, and finally on addictive behavior and other problems of appetite.


This can be seen in the spread of religiously based mutual help societies in Western Europe during the 17th and 18th centuries. Responding to the widespread overuse of alcohol, they launched temperance efforts in Europe, which spread to America. Many of these early attempts at appetite control included temporary residential support and pledges of abstinence. Key principles embraced by these mutual help groups included disclosure (confession), admonition, commitment, and conversion of others. By the 1800s, the spread of these principles had influenced the development of the Washingtonian and numerous other small groups.


Before World War II, however, the term “therapeutic community” occurs only once, when it was applied to the care of orphans in 18th century Russia. It was next revived in wartime England at Northfield Hospital, a facility dedicated to the treatment of traumatized British troops. There, two psychiatric innovators, Maxwell Jones and Tom Maine, sought to reapportion authority and decision-making between staff and patients. .


They began referring to the democratic therapy that they introduced at Northfield Hospital as a therapeutic community, designed to reverse the dynamics of the traditional psychiatric hospital, which many had come to believe infantilized patients, exacerbating their disability and rendering them incapable of functioning outside the hospital environment. Patients in Northfield psychiatric units became the active decision makers, taking on increasing responsibility for ward management. Early discussions among these pioneers resulted in five basic assumptions: two-way communication at all levels; decision-making at all levels; shared leadership; consensus in decision-making, and social learning by social interaction with emphasis on the here and now.


The horizontal, open system of communication, based on those five principles, was itself assumed to result in healing. It did, in fact, produce marked improvement among community members, and such success made the need for individualized treatment plans seem unnecessary (a notion that would later become doctrine in American drug treatment therapeutic communities). Maxwell Jones went on to become a teacher of this method in Europe and the United States throughout the 1950s and 1960s, influencing younger psychiatrists, particularly at state psychiatric hospitals in Washington, Oregon, New Mexico, and other Southwestern states. However, not until the late 1970s did Jones become aware of and engage with the American drug treatment therapeutic community movement.


The drug treatment therapeutic community was not introduced by any of the nurses or psychiatrists who, inspired by Jones, sought to develop similar treatment models. Its origin is attributed to a group that emerged in Venice Beach, California, in 1958, when an Alcoholics Anonymous member, Charles E. (Chuck) Dederich, started an organization he called Synanon, embodying mutual help principles of Alcoholics Anonymous and characterized by hierarchical structure, a semi-open communication system, and small group interactions focusing on behavioral change.


Not unlike other charismatic and gifted figures, Dederich brought his own background—corporate, Midwestern, and Depression-influenced—to the organization he founded. As is often the case when strong leading theoreticians mount efforts designed to alter human behavior, the organization took on the personality of its founder. Imitation of the leader—in dress, language, and general demeanor—became a defining characteristic of Synanon and an influence on subsequent therapeutic communities.


Dederich launched Synanon by breaking away from the Alcoholics Anonymous group he had been attending. Within the tradition of Alcoholics Anonymous, anyone can pick up the Big Book and start his own meeting. When Dederich and the few members who followed him started their meeting in Venice Beach in 1958, the community was loaded with “alkies,” “pill-heads,” and a few “junkies.” These people, living on the edge of society in the pleasant, hospitable, Southern California beach community, were sleeping on the beach, begging for money, making drug deals, and essentially staying intoxicated with the drug of their choice or whatever else they could get. It was a setting ripe for an evangelical salvation-oriented mission.


With the help of a dedicated few, Dederich and his followers obtained funds to open a club and, in a tradition easily traced back 200 years, encouraged folks to drop in for conversation in hopes of gaining sobriety. Dederich began holding long meetings in which his innate verbal talents and wide range of interests—from corporate structures to Zen and Transcendental philosophies—drew growing audiences and proved a powerful magnet for membership.


Hearing of these meetings, the availability of food and rumors of easy sex, a few heroin users recently released from the California prison system dropped in. Contrary to their expectations, they were immediately confronted by a loud, bombastic host, who assured them they were welcome, but only if they were willing to help out. “There’s no free lunch,” Dederich told them, and this proved an attractive challenge to some, since it was such a departure from the traditional social work style they anticipated.


A nascent community came into being made up of Dederich’s Alcoholics Anonymous cadre, former prisoners, quasi-homeless addicts from the beach, and an upscale contingent of musicians and other artists. Core members from outside the area began moving in, renting the readily available small cabin rooms along Venice Beach. Later in that first year, the group acquired an armory on the beach in Santa Monica, which gave members a chance to live together, pool their funds, share meals, and begin to seek financial support in the community, soliciting donations of cash, foodstuffs, and other living supplies. It also challenged Dederich to organize, preside over, and control community life.


A large man, highly verbose and partially deaf, Dederich spoke at length and high volume. He loved to argue and debate, inspiring heated confrontation among members. These confrontations became a common style of interaction within the group, valued for the relief that many members claimed such abrasive exchanges brought them. Soon formalized, this mechanism was first called “The Synanon” after the name of their organization. By 1964 the Synanon began to be referred to as the “game.”


It is from the Synanon game that the therapeutic community encounter evolved. What Dederich added to the fundamental Alcoholics Anonymous mechanism of self-disclosure was the muscle of confrontation. Alcoholics Anonymous rejects both invasiveness and cross-talking. Although no one at an Alcoholics Anonymous meeting interrupts, questions, or challenges a speaker, the game encouraged this kind of spirited exchange.


As the game developed, so did the ethical demands of mutual responsibility. Although no drug use was an early requirement of the group, many members continued to use. Troubling questions arose: What then is the responsibility of others in the group? Are they obliged to expose their drug-using fellow members?


The issue came to a head at what later became known as the “Night of the Big Cop-Out,” when a number of drug users were “outed” and others “copped to” their use. At this point, the role of the community as monitor was established along with the principle of expulsion from the group for drug use.


As a daily schedule took shape, work tasks necessary to operation of the community were assigned and a schedule of daily seminars established to broaden the intellectual horizon and knowledge base of members. A distinct corporate-like hierarchy was formed, with a top-down structure based on coercion (“our way or the highway”) and leadership determined and rewarded by Dederich. The early rewards included special living quarters, special food, access to vehicles, and the ability to acquire girlfriends or boyfriends and sleep with them. (The euphemisms were “courting” and “steady dating.”)


Early on, Synanon began organizing the process of drug treatment into a series of phases. Phase One was live in and work in; Phase Two, work out and live in; and Phase Three, live out, work out, and maintain membership. But very soon, by 1960, Phase One had grown from 2 to 6 months in response to relapse among members in Phases Two and Three. By 1962, during a period of rapid membership growth, Phase One was extended to at least 1 year. Nevertheless, relapse continued to occur in Phases Two and Three. As a result, the work out and live out phases were entirely eliminated in 1964, with Dederich rationalizing that “Our members remain healthy and drug free while with us—so that we are obviously a healthier community than is the greater society.” At this point, the effort once labeled by Life magazine as a “Miracle on the Beach” began its drift into increasingly wilder utopian community fantasies and ultimately into a cult capable of criminal behavior (pleading no contest to charges of soliciting an assault and conspiracy to murder).




Early Expansion


Not surprisingly, and consistent with the experience of other psychosocial movements, there were breakaways from Synanon by 1964. These breakaways, while troubled by the Synanon’s flaws, still took with them a deep belief in the essential elements of a treatment model that had made it possible for them to achieve and sustain abstinence. They also, however, carried with them a vision of treatment as redemption and the Synanon belief that they had the only right answer. Theirs was a point of view that perceived addiction, if not as a moral weakness and sin, then as a disorder of character. Thus they were not only entitled to, but charged with, correcting such flaws by whatever means necessary within the limits of the law.


It was at this moment that new opportunities were created by growing demand for a response to the seemingly intractable problem of addiction to heroin and other illicit drugs. By the early 1960s, heroin use was expanding, particularly in urban America. The accompanying increase in crime brought to the surface public frustration with the failure of stern anti-addiction measures to effect change. Longer and longer minimum mandatory sentences for drug law offenses and civil commitment of addicts for treatment with lengthy stays in federal hospitals did not produce abstinence outcomes.


The notion that abstinence might not be a rational expectation had surfaced back in the early 1950s when Victor Vogel, MD, who then oversaw addiction treatment at the United States Public Health Hospital at Lexington, Kentucky, wrote that “If treatment results are compared with those in other chronic or recurrent diseases such as TB… arthritis… hypertension … diabetes … or cancer—results in this field (drug treatment) are good.” But this early glimpse of addiction as a chronic disease was ignored. Both the public and the afflicted either hoped for or wanted an answer called “cure.” Synanon had promised such a miracle and so did the first spin-off, Daytop Lodge in New York.


Daytop Lodge was a research project based on Synanon. It was supervised by Brooklyn’s Chief of Probation Joseph Shelly and his lead psychologist Alex Bassin. The acronym stood for Drug Addicts Treated on Probation. The population consisted of 35 male felons who accepted treatment at Daytop under probation supervision rather than prison sentences. This marked a serious departure from the mutual help members involved in volitional recovery. Money in the past was begged or provided as charity. Now it was underwritten by government and administered by a criminal justice agency. It should be noted that this was the first step in what came to be known as therapeutic community institutionalization, and a new term, “ex-addict,” came into use. The project had a shaky start with a rapid turnover of leadership. In October 1964, under a new and more experienced leadership team and with increased financial support from New York City, the program was reorganized, and Daytop Lodge morphed into Daytop Village.


Probation was no longer a requirement for admission, and the program now accepted women. A board of directors was formed, chaired by co-founder Monsignor William B. O’Brien, a Bronx priest with strong ties to the New York archdiocese. Alex Bassin joined the board. Daniel Casriel, M.D., a psychiatrist who had written the first book about Synanon, So Fair a House , was now psychiatric director and David Deitch was clinical and program leader. Soon, a growing number of candidates sought admission, and by the end of 1965, there were 100 members/residents in a larger facility.


In 1966, New York City’s mayor, John V. Lindsay, recruited Efren Ramirez, MD, a psychiatrist from San Juan, Puerto Rico, to coordinate the city’s narcotic treatment programs as commissioner of the city’s new Addiction Services Agency. Dr. Ramirez had already developed systems of community engagement, protracted client induction processes, and treatment approaches similar to those of Daytop Village (“Daytop”). Ramirez developed a close working relationship with the program, and Daytop staff became a resource for him as he set out to expand the city’s response to a growing heroin epidemic. It was Ramirez, trained in the Max Jones model, who persuaded Daytop, which had been calling itself a “humanizing community,” to adopt the term “therapeutic community” to better describe its approach.


Dr. Ramirez was soon joined by Mitchell S. Rosenthal, MD, a psychiatrist who had developed an alcohol and drug treatment hospital unit at the Oak Knoll Naval Hospital in Oakland, California. There, he had introduced many of structural and group characteristics he had observed at a Synanon facility in San Francisco. Ultimately, Ramirez made him deputy commissioner for rehabilitation.


Commissioner Ramirez was also reaching out to other young psychiatrists in hopes of expanding addiction treatment. He created a weekly get-together of Deitch, Rosenthal, and a young psychiatrist still in residency training, Judy Densen-Gerber Baden. These meetings provided the impetus for an explosive growth of the model in New York City. Rosenthal developed Phoenix House, and Judy Densen-Gerber created Odyssey House. Daytop lent staff to each of these projects, and help also came from other former Synanon members.


In short order, these projects spun off other new starts: Samaritan Village and Project Return in New York City; Gaudenzia in Philadelphia; Village South in Miami; and Gateway in Chicago. All of them shared many similar beliefs, hierarchical structures, group activities, and goals.


There was also a significant role in the expansion of the therapeutic community played by the young psychiatrists who finished their training and served in the US Public Health Service. The earliest concentrations of addiction treatment were located at the US Narcotic Farm in Lexington, Kentucky, run jointly by the Public Health Service and the US Prison Service, and a similar facility in Fort Worth, Texas. These facilities accepted voluntary admissions as well as addicts convicted in federal territories or found guilty of federal offenses.


Three of these psychiatrists emerged as leaders in addiction research and treatment. Jerry Jaffe, who was to become the first White House director of the Special Action Office for Drug Abuse Prevention, currently referred to as the Office of National Drug Control Policy, became familiar with therapeutic community methods at Daytop while at Albert Einstein Hospital in at New York City. Recruited by the Department of Psychiatry at the University of Chicago to serve as the director of drug abuse treatment programs for the State of Illinois, he subsequently recruited two Daytop staff members who helped him to further develop Illinois’ first therapeutic community, Gateway Foundation. In order to secure a facility for Gateway, Jaffe took a lien against his own home so that the therapeutic community model would be part of the broad array of programs, from outpatient detoxification through methadone maintenance, he created in Chicago.


A second US Public Health Service psychiatrist, Herbert D. Kleber, had his introduction to addictions at the Lexington Hospital and went on to the Department of Psychiatry at Yale’s medical school. There, he recruited Daytop staff to develop a separate Daytop Connecticut in New Haven. Kleber was subsequently tapped to become the Office of National Drug Control Policy’s first deputy director for demand reduction. Another US Public Health Service Hospital psychiatrist, Fred Glaser, helped bring the therapeutic community program Gaudenzia to Philadelphia while teaching at Temple University.


This rapid spread of therapeutic communities was made possible by program members seeking a cure and communities in search of new and better ways to confront addiction. Unlike the Alcoholics Anonymous movement, which holds that “members are in recovery not recovered,” the therapeutic communities believed that cure was possible. This belief was reinforced when peers were seen to succeed. Use of the term “ex-addict” grew, and the expansion of the therapeutic community was now fueled not only by former Synanon members, but by graduates of these new and exciting programs.


Proliferation of the therapeutic community was carried on a wave of optimism characteristic of the era—a period of seemingly infinite possibilities, before the war in Vietnam clouded the political landscape. The climate of the times made possible the spread of therapeutic community doctrine by outsiders, for here was a treatment model with no academic provenance or research history that essentially invented itself. Pioneering psychiatrists who embraced the model did not come from the medical or mental health mainstream, and few of those first-generation program leaders had any professional credentials at all. What they did have was an ideology. The concept of giving to get—the notion of helping others to facilitate one’s own recovery—was a philosophical cornerstone, as was the belief that healing was possible only when one was part of something greater and more important than oneself. The men and women who staffed the early therapeutic communities strived to submerge their separate identities. To them, the golden word was “we.” Many of these early staffers—formerly gone astray, isolated and addicted themselves—needed that merged identity to heal themselves before they could help others heal.


As Deitch wrote many years later,



These outsiders … created humanizing communities that espoused dignity of all people, equality between races and sexes, nonviolence and peace, heightened consciousness and spirituality, and action as the road to personal and social change. These first-generation ideologists committed themselves to a way of life that provided health, safety, caring, and honesty—sometimes brutal honesty. They censured deception, cheating, and gain at others’ expense. The original version of these early crusaders—a vision that still holds true today—was a commitment to live and act as agents of positive social transformation. We believed that what goes around comes around.




The Formative Years


Admissions


The mindset of first-generation US therapeutic communities was shaped by the realities of the heroin epidemics of the 1950s and 1960s and the lack of much in the way of alternative treatment resources. Candidates for admission were not then greeted with open arms—admission, it was felt, had to be earned. One had to prove oneself ready for treatment. In some programs this meant demonstrating that one had hit bottom.


Therapeutic community membership was then, as it is now, deemed to be voluntary. But few candidates at any time have sought admission without some form of persuasion, generally from family, employers, or the legal system. The pressure on addicts to seek therapeutic community treatment was particularly strong in the 1960s, when there was great threat of arrest or civil commitment, particularly in New York, which held the greatest concentration of first-generation therapeutic communities.


Admission to most therapeutic community programs then generally involved heavy doses of dissonance. These ranged from the demand that applicants demonstrate commitment by daily telephone calls to the program and long waits in the interviewee chair. Interviews could be conducted by three or four program members who would challenge the applicants’ candor, belittle their claims of sincerity, and demand they drop their drug user’s street facade and adopt new language and behavior. Clearly, this type of challenge and the levels of dissonance discouraged many applicants and prompted others to leave soon after admission, feeling both angry and confused or compromised. For those who stayed, however, many would subsequently claim that the dissonance experience left them more invested in the process that followed.


The Role of Family


Then as now, the pressure that brought many applicants to treatment came from their families. This posed something of a problem for the therapeutic communities, which wanted to keep families engaged but distant. They needed families to understand that they were vulnerable to manipulation and exploitation and must to learn to resist pleas for help from their addicted children—particularly for money.


A favored practice for dealing with families that remained committed to their addicted children was bringing a group of families together to discuss their concerns and answer their questions. These sessions led to the creation of an education program that dealt not only with therapeutic community goals, structure, and methods but also with the stages and nature of addiction. This practice was, in many ways, an innovation that was adapted by other groups to help family members deal with such other disorders as mental illness, autism, and alcoholism.


Families were taught, as were their loved ones in the program, the concept of responsible concern, the notion that when you care about someone, you must set limits on their behavior, which may, at times, mean denying them money, shelter, and other benefits that might enable addicts to keep using without facing the natural consequences of their behavior. This later evolved into the tough love philosophy, one that would become a central theme to a self-help movement for parents and others intimately involved with addicts and others with problem behavior.


Eventually, many therapeutic communities formed small groups for family members, where the staff would lead discussions about their attitudes, behaviors, and values. This was considered a way to explore conflicts that potentially abetted their loved one’s drug use. The preferred means of encouraging frank discussion was the encounter group that aimed at revealing differences between stated goals or needs and actual behavior. The intensity of interaction at these family groups, however, did not rise to the level practiced in the treatment community, and there was little acceptance or use of harsh confrontation.


The Hierarchy of Roles


Once admitted to the residential setting, the new member was introduced to the community’s elaborate and hierarchical structure, much of which remains as a cornerstone in the American therapeutic communities to this day. Rank and status were based on work assignment, and newcomers were assigned to what was considered a bottom function, such as cleaning the toilets or washing dishes. These jobs were meant to make clear to the client his position at the bottom in status, and the need to do the job well in order to gain status and move up in the hierarchy (which was often called “growing up”). But work was only one element on which moving up was based. Attitude, change, and commitment to the treatment community were also considered. The theme constantly reinforced by leaders to those beneath them was, You can have my job and you can be in charge, but you must earn it!


Each of these work assignments was real and necessary to the actual functioning of the community. Facilities needed to be cleaned; food prepared and cooked; cars oiled, gassed, and repaired; walls painted; and rooms renovated. Household needs had to be met, and effort was made to solicit contributions of everything from milk to gasoline from the greater community.


All donations were accepted: used clothing, slightly stale bread, fruit and vegetables, old dishes, and cookware. It was all needed. There were also cash gifts and, by incorporating as nonprofit organizations, therapeutic communities were able to add the inducement of a tax deduction to the selling points of personal recovery and self-reliance.


Much also had to be done to run what was, in reality, a small business—write the letters; answer the phones; make agendas; ensure positive behavior, coordinate between departments, and represent the therapeutic community in the outside world. Each task was the responsibility of a specific department. Each department had its place within the hierarchy, and one’s status depended on one’s role within the department and the department’s place within the community. One gained status first by moving up within a department and then by moving on to a department with a more complex or demanding function.


Over time, each member, depending on his investment in treatment (judged to be doing well by peers and elders) was promoted upward. The promotions were done with drama and praise and were part of the reward system. Each promotion was discussed internally and was used as an example to guests and visitors to show how the therapeutic community structure rewarded one with increasing amounts of responsibility for areas of work, productiveness, and oversight of others.


During this time, youth and adults were mixed together, as were genders. All were treated with the same methods, expectations, and accountability demands. There was then no consciousness of a need for formal education for this predominantly adult population, and vocational training was done on the job, in the classic apprenticeship tradition. The need for supervision and oversight within the departments and within the community created an interesting tension between trust and scrutiny.


The Interactive Healing Life


Group processes were then and still are the lifeblood of the therapeutic community. Every day, every member, staff, or client, and even steady visitors and friends, became involved in one group process or another.


The community began the day with a morning community meeting where concerns were expressed and problems were solved. These meetings always began with a prayer or a statement of the program philosophy. Each therapeutic community group strove to be unique, creating its own language and terms to describe shared activities common to all other therapeutic community groups. Program philosophies became a critical means of identification and morale building. Many were created by the members themselves and reflect the spirit of the times and the intense need for affiliation, membership, and family. Indeed, the greeting, “Good morning, family,” permeated most American therapeutic communities and (at least until the mid-1970s) most therapeutic communities outside the United States.


During these early formative years, the problems that came up at morning meetings often dealt with issues of survival, such as getting food for the table. Others were more mundane, like dealing with laundry, announcing visitors that day, or welcoming new members. Some were personal disclosures, making the community aware of some member’s personal distress. These morning meeting public disclosures were greeted with “reach-outs,” expressions of concern and support from others. There were “pull-ups” for tasks left undone and also “push-ups,” applause and recognition for tasks accomplished. These activities generated positive feelings—laughter and energy to start the day. The meetings usually ended with mutual hugs.


Intellectual Exchange


There was usually a break in the workday in mid-afternoon for lunch followed by the “daily seminar.” Participation was mandatory for all, including the leadership. The goal of the seminar was to broaden the intellectual vista of community members. It was an opportunity to make them familiar with ideas and concepts that they had perhaps never heard of before. Everyone became a tutor or mentor, reading up on subjects so it could be brought to the group. There, members were encouraged, cajoled, and sometimes coerced into taking part in discussion of matters that ranged across vast subject areas. Philosophy was discussed, along with science and literature. Sessions might focus on the works of Nietzsche or Freud or the writing of Hemingway or Faulkner. The seminar was an important part of daily life, not only for its content, but as a means of helping members learn to conceptualize and verbalize.


Small Group Interventions


Generally, every evening was reserved for small group process. These sessions were at first called “encounters,” although some used the language of Synanon and called them the “game.” One dimension of the encounter was its formation, for the makeup of each group was usually decided by elders in the program drawing on information they had received from various members. No less than twice weekly, when the call went out “encounter-time,” every member experienced a moment of tension and anxiety. One never knew until that moment who might be in their group and how they might be perceived or challenged about their behavior, attitude, or social contribution to learning to live drug free. Encounters involved challenge, and often exaggerated elaboration of a person’s behavior would be used to elicit truth, the admission of error, and acceptance of corrective action.


In 1968, the psychologist O. Horbart Mowrer, who visited Daytop frequently and was certainly in the behavioral therapy camp, made a unique contribution to the encounter group by adding a new aspect—promise-making. Members would now make a commitment to another (or many others) in the group to change or adapt some specific behavior. One did not necessarily have to believe in the need for or use of this behavior, one merely had to practice it. Subsequently, such phrases as “act as if” or “go through a motion” became a commonplace part of early therapeutic community life.


Also in 1964, Deitch and Casriel began experimenting with groups lasting 18–30 hours. This was not a physically impractical notion at a time when all community members, including the directors, paid staff, and program elders, all lived either in the same facility or one close by. Therapy was an ongoing process, 24 hours a day, and interactive dialogues were primary aspects of community life.


These long-lasting groups became known as marathons, and a set of methods and procedures slowly evolved. The staff who selected marathon participants would consider how the process could be the most useful for the member. However, common to all was the expectation of going deep toward the past, toward unresolved guilt and unrevealed strengths to discover, in the process, that one could be vulnerable in the face of fears and, by doing so, gain strength. The format began with autobiography, particularly aimed at early feelings of fear, shame, and defenses that became self-defeating.


As hours passed and intimacy grew, an atmosphere of caring emerged with expressions of compassion, and attempts at resolution became key. This experience was heightened by the combination of sleep deprivation, limited external stimuli, and selected stimuli to provoke moods (usually music, mirrors, drawing supplies, and occasional props such as photographs). Usually, by 24 hours, all had experienced a sense of catharsis and acceptance by the others over conflicts, guilt, and regrets.


This marathon session would be followed by a break during which each participant was asked to be alone and reflect on the experience. They were usually escorted by a nonparticipating member who had experience with the process to a quiet, private space to sleep, eat, and think. After this 6-hour break, participants reconvened for feedback. This process became very carefully regulated after the first few years, with the participants asking for feedback being given a scribe to record those portions of the feedback they requested. After feedback, the members would talk about their commitments to the group.


Considering the regressive possibilities of this type of group, there was a safety net provided by the fact that they all lived together in a larger community of others equally committed to being there for each other. Most often, this experience resulted in peaks of love and compassion and group bonding. At this point a follow-up plan could be developed to monitor the keeping of commitments made during the marathon.


These marathons and shorter versions, with fixed targets of inquiry known as probes, ultimately morphed into a static group that met weekly and where the emphasis was on maintaining the intimacy created by the marathon or probe for further deep work. By 1979, static groups were created for members regardless of marathon participation.


The General Meeting: A Response to Crisis and Bad Behaviors


Unlike the daily morning meeting, when one heard the announcement of a general meeting, therapeutic community members immediately headed for the meeting space knowing something big or bad had happened. Here, unlike at traditional meetings, the chairs were not arranged in a circle, but rather in a classroom format, with the front reserved for standing elders who had a message to deliver. These meetings did not occur often. When they did occur, it had to do with a serious threat (usually by a member’s behavior) to the community’s two principal taboos—no violence or even the threat of violence, and no drugs or alcohol. (Cigarettes were used by all members, and smoking was considered normative.) Such violations usually called for banishment of the offender. The meeting was to bring focus to the event, generate anger toward the offender, challenge the offender’s right to remain, and vent fury at the threat to the community. The decision about whether an offender stayed or was banished was made as a result of the group’s assessment of the offender’s display of regret, seeking of forgiveness, and pleas to stay. Such a visible display and catharsis for the entire community was considered necessary for safety and the community’s drug-free goals.


Public acts of contrition also permeated normal daily life. Signs were hung around member’s necks describing their failures to be honest, their propensity for manipulation, or some other set of behaviors requiring a high level of focus and embarrassment to the person. These signs were often quite creative and developed for a specific individual and the particular offense. Other signs for more common offenses were used routinely and could be kept in a closet until needed.


Treatment Duration


All of the New York therapeutic communities and many others maintained a phase system with an average prescribed length of stay, in order to complete all phases, of 2 to 2.5 years. The early therapeutic communities believed in a full character makeover and the creation of a new prosocial role in society. Indeed, such roles were made possible by becoming change agents and taking on careerist roles of therapeutic community staff, which were in high demand.


Understandably, considering the length of the prescribed stay, the problem of sexual needs and interaction was always present. Many attempts were made to resolve this dilemma. At first, permission to have sex was given if the heterosexual couple was behaving well in their community life, presented as stable in courting, and had been in treatment long enough to presume greater stability. This approach varied from program to program and often within the same programs.


The tradition at that time was to insist on couples’ education groups, followed by encounter groups for couples meant to explore feelings and conflicts. When such couples demonstrated that the relationship was not compromising their positive treatment engagement, they were permitted a designated space and privacy for a given time period. This ranged from 2 hours for beginners to an overnight visit for residents who had been in treatment for a considerable time.


By the early 1970s, the controversy and complexity of permitting, condoning, monitoring safety, public relations, and couples’ conflict resolution soon gave way to exhaustion and brought about an official end to this era. Henceforth, sexual identity and romance could be discussed, but sanctioned sexual interactions were no longer permitted. The admonishment—You are here to get better; those other aspects are off the table and impede your personal recovery—eliminated the conversation but not the problem. However, sexual interactions between staff and clients continue to plague the recovery and mental health communities to this day.

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Jan 19, 2020 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on The Therapeutic Community for Drug Abuse Treatment : A Journey Yet Unfolding in the Recovery Movement
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