EDITOR'S NOTE: This article on the evolution of the therapeutic community (TC) group model in addiction treatment is an excerpt of an address by Peter Provet at a plenary session of the World Federation of Therapeutic Communities' 2006 conference, a September gathering of leaders from more than 50 countries in New York City. Provet is president of New York City-based Odyssey House, a multisite addiction treatment agency offering addiction treatment, medical care, and support services to more than 1,000 adults and children. He is a clinical psychologist with more than 20 years of experience in treatment and in managing programs for adolescents, adults, and families with substance abuse and mental health problems.
As the central protagonist of group-based drug treatment, therapeutic communities (TCs) lead the way in harnessing the power of group dynamics to exert individual change. Evolution of the model calls for maximizing the clinical potency of the TC group methodology as we continue to integrate other clinical approaches into the treatment regimen.
Opportunities include utilizing time more efficiently by re-examining how clinical intervention takes place on a 24-hour, 7-day-a-week basis, and providing on-site/co-located services that ensure, for example, that teachers and medical personnel are knowledgeable of TC concepts and able to incorporate clinical directives in their interactions with residents.
Also key is the productive utilization of “group transference” where the group is identified as a benevolent force with an attractive identity, and confrontation is used in a strategic manner, with positive reinforcement far outweighing negative reinforcement and punishment. This is further enhanced by a redoubling of efforts to demonstrate core TC values of responsible love and concern, and by helping individuals in treatment fill the vacuum created when addiction and concomitant behaviors are removed.
Additional efforts to maximize TC potency include: integrating traditional psychotherapy; fostering a more compassionate and transparent TC management style; and capitalizing on the synergetic partnership of counselors in recovery with those who are not. Clinical managers must also resist pressure from licensing and funding bodies to move away from a peer leadership model in favor of staff-led interventions, and must become promoters (and role models) of emotional sharing, healthy physical activity, and rigorous intellectual pursuits—a role that further extends to promoting treatment efficacy to funders, policy-makers, and referral sources.
Residents' intrinsic motivation
Fundamentally, clinical potency within the TC is maximized when its members achieve “intrinsic motivation.”
In the U.S., entry into treatment has increasingly relied upon criminal justice referrals and mandates—alternatives to incarceration.” Depending on locality, such efforts have become quite systematic, with all relevant partners (e.g., judicial, prosecutorial, defense) working in concert. This movement has been essential as drug and alcohol abuse is now recognized more as a medical disease, rather than a moral failing or criminal enterprise. Solidifying this critical shift, however, will take many more years of research into the biological and genetic correlates of addiction, and ongoing public education.
Simultaneously, however, this shift has placed greater pressure on treatment programs to motivate clients to achieve sobriety and a meaningful recovery based on self-examination and self-awareness. Stimulating initially dormant “intrinsic motivation” is now more important than ever. If unsuccessful, the client simply “does his time” in the TC rather than jail and returns to the community largely unchanged, primed for relapse. As a result, most early treatment interventions can be best conceptualized around the goal of shifting the addict's motivation from that of extrinsic to intrinsic sources.
One unifying principle around which this effort can be based may be thought of as enhancing group transference. The individual enters the TC environment typically resistant to change, negative, and certainly impressionable. The group environment, represented by fellow peers, staff, the physical structure, operational guidelines, and all elements of daily implementation, must be logical, consistent, and attractive. The perceived potency of the group should be great—most importantly, however, in a benevolent form. For some residents, the experience of the TC as authoritarian and rigid is a contributing factor in early treatment dropout.
Of course, achieving initial behavioral compliance is essential. For the community that regularly, if not daily, accepts and integrates new members, “fresh off the street,” individuals must comply. Too often, however, our treatment environments are perceived as hostile (conveniently reframed as “confrontational”), with far too little responsible love and concern. Shifting this environmental tone need not sacrifice the critical behavioral underpinning of the TC to offer both positive and negative feedback within the context of earned reinforcement.
Of course, “tough love” has its place in the TC. Through years of drug use and related addictive behavior, the addict's defenses—denial, projection, repression, grandiosity—dominate his personality and become rigid, often impermeable. A degree of breakthrough is essential if meaningful change is to occur. The issue is more one of timing and technique. When and how is it best to assist this complex process along?