Frequently Asked Questions About the TC
Where do I get information about the TC?
General information about the TC may be obtained from various Internet sites or websites of TCs, such as Daytop Village, Walden House, Samaritan Village, Phoenix House, etc. The National Institute on Drug Abuse (NIDA) has also publications on the therapeutic community. Various Internet bookstores, i.e., Amazon.com, BarnesandNoble.com, Cheapbooks.com, e-bay, etc. sell in their sites books on TC.
Are there training programs available to learn about the TC and how to work in one?
Daytop International, a division of Daytop Village Inc. based in New York, conducts overseas training on TC with grants from the U.S. Department of State's Bureau For International Narcotics and Law Enforcement Affairs (INL). Daytop hosts international trainees from different countries for a more indepth training on the processes of the TC for a duration of a few months at its New York upstate facilities. For more information on the Daytop training, inquire at int@daytop.org
What is the origin of the TC?
The basic principles of the TC go back to ancient times when communes exist for the purpose of healing the sick in spirit or soul through religious awareness or spiritual awakening. The same principle of community as the source of healing and support was found in more recent spiritual movements such as the Washingtonians, the Oxford Group, and more recently, the Alcoholics Anonymous (AA). Modern therapeutic communities come from two independent but kindred roots. The first was the result of revolution in social psychiatry in Great Britain in the '40s when psychiatrists treating war-traumatized soldiers began experimenting with self-help approach to group therapy. This new movement in social psychiatry, popularized by the writings of Maxwell Jones of his experiences at Belmont Hospital, brought about the creation of self-managing psychiatric wards called the Therapeutic Community, as first referred to by Tom Main. This brand of TC became known as democratic TC, which has its beginning in mental hospitals for mental patients. The American brand, called the concept-based or hierarchical TC, started in California in the late 50's by an ex-alcoholic and AA member, Chuck Dederich. Together with a group of recovering alcoholics and ex-addicts, he developed a variant of AA group meeting that was highly confrontive and intrusive. This emotionally charged group process eventually was called the synanon, the word from which the organization called Synanon derived its name.
What evidence supports the effectiveness of the TC?
In studies conducted in the United States, the TC has repeatedly proven to be effective. Using the following outcome measures or variables: drug use, criminality, productivity (work or schooling), and psychopathology, several research studies found that TC clients who spent between six to twelve months in treatment were likely to do significantly better on those measures following treatment compared with those who left treatment prematurely. Retention in treatment was the crucial variable and determined positive treatment outcome. However, until today the greatest challenge for TCs (and other drug programs) is keeping clients long enough in treatment for the curative effects of the TC or the treatment process to take hold on the individual. It is an accepted fact that a great number of clients dropout during the first month or two of treatment.
How well the same outcome variables hold true in other countries or culture needs investigation. Preliminary observations in some countries that have had well established TCs indicate that there are reasons to believe that to a certain extent these variables can be generalized to those settings.
The TC approach seems harsh and counter to the recent development in motivational interviewing techniques.
Taken out of context, the TC tools or methods seem harsh or brutal. Careful observations of how the TC tools are applied by experienced TC staff under a truly functioning TC, give one a different feeling or impression. Membership in the TC implies consent and the person's trust to the community that it will resort to the best possible way to correct his shortcomings or bad behavior. In other words, TC must be participatory, where each member gets actively involve in his treatment. The task of the staff is to create credible role models, a physically and emotionally safe environment, and invite all members to get involve in the treatment process. Failing to create these conditions, clients will find the TC very intrusive and will provoke resistance. This explains why in the early days of the TC the emphasis was on motivation. The prospective client must come to treatment on his own and voluntarily. Since this was a rather unrealistic expectation for the often confused and wrongly motivated drug-addicted person, the intake interview or initial interview process was developed to facilitate genuine motivation. When defenses were broken down and trust was created, rapport increased and openness to the TC lifestyle developed.
The TC uses persuasions and take pains in enlightening clients through seminars and various meetings of the rationale of how certain things are done and for what purpose. However, in practice residents are expected to do as told first, then later he may "respond" for clarification to the person who gave the order or instruction. In the orientation phase, new clients are not only told about the house rules but also the connection between the rules and the need of the community for order and security, and how rules and structure are ultimately tied to the goal of each client to benefit from treatment and stay drug-free.
Can the TC method work for other addictions besides narcotics?
The TC's perspective on addiction and the drug addict posits the view that addiction is a condition that involves the whole person and substance abuse is the symptom of an underlying personality disturbance. Therefore, recovery from addiction does not only require quitting from drugs but more importantly making significant changes in one's dysfunctional behavior, feeling, thinking, and socialization. This global change process includes a change in lifestyle that promotes "right living," which in turn supports the goal of sobriety.
This global perspective on addiction and the addicted person, allows us to generalize the approaches of the TC to address different forms of addiction.
From what I know, only ex-addicts or recovering addicts can work effectively in the TC. What is your opinion on this?
Historically, concept-based TCs were established or operated by ex-addicts who themselves were treated in TC. This was particularly the case during the diffusion process of the TC from Synanon to the next generations of TCs. As the TC increasingly became part of mainstream drug treatment and TC's started to rely heavily on state or federal funding to survive, government or state regulations demanded the TC to comply to traditional medical or mental health oriented treatment procedures. This paved the way to the influx of traditional health and mental health professionals into the TC, such as social workers, psychologists, nurses, psychiatrists, etc. Nowadays, it is common practice for ex-addict and professional staff, including educational and vocational personnel to work hand in hand in a TC. This merging takes on different forms, but the ideal set up is one of a "trans-disciplinary" staffing pattern of working as a team, instead of according to turf.
In other countries where the idea of an ex-addict becoming a therapist was slow to get social acceptance, TCs were generally established by professional staff who obtained training in the U.S. or were trained by U.S. or European TC experts. In these TCs, ex-addict staff often work as subordinates to professional staff.
What is the source of the seeming inability of professional mental health and ex-addict staff to recocile their differences and work as equals in TC?
Modern conditions have forced both ex-addict and professional staff to work together in the TC as "equals." In actuality, there are disparities in terms of pay and work hours or workloads between the two staff. Professional staff generally have academic degrees and more educated compared with most ex-addict staff. The salary scaling, for example, favors licensed social workers or psychologists than ex-addict staff who often occupy counselor positions. In most cases, counselors are generalist practitioners depended on to "run" TC operations, whereas professional staff are confined to specific clinical tasks, i.e. evaluations and assessment, special therapeutic interventions, educational or career counseling, etc. Because of greater or total involvement by ex-addict staff to the therapeutic processes of the TC, they often feel they are in much better position to have the final say on clinical matters.
Although this merging of ex-addict and traditional mental health professionals is beset with problems, as they battle for supremacy in having the final say in treatment matters, they both can learn from each other to become effective staff. On the part of ex-addicts, the animosity has a long history that dates back to the beginning of the TC in the United States. Synanon took the road of self-help and charted a new path in the helping field by shunning professionals as a reaction to the dismal failure of medicine and the social sciences to treat narcotics addiction in the '50s and 60s. "It takes an addict to understand another," became the pervading belief and rationale. For a while they did well on their own, until the need for "legitimacy" as a treatment method had forced the TC to employ professionals to provide medical, psychiatric, psychological, educational, vocational, and social services as part of traditional medical and health practices required by certifying or licensing agencies for funding purposes.
On the side of the professionals, the "It takes an addict to understand another," was taken as an excuse to exclude them from other TC therapeutic processes. The sense of intellectual superiority in diagnostic and therapeutic interventions, as taught by traditional social science, did not help the cause of professional staff, for it only added to the mutual alienation between the two camps.
What seems to work is the attitude of openness from both sides. Certain professionals who come to work in the TC with their professionals "hats" off and with genuine interest to learn how the TC works and perceived as non-threatening, integrate themselves into the TC effectively. Some ex-addict staff who have grown emotionally more mature and accept their limitations are less inclined to hide their feelings of inadequacies behind such rationalization as "only an addict understands another." The different knowledge-bases and perspectives of professional and ex-addict staff are complimentary and if utilized well can enrich the TC processes. To be able to work together productively, they must respect each other and recognize their unique contributions to the TC within a "trans-disciplinary" staffing model.
Is the TC based on a religious approach?
The TC is not based on a particular religious belief but there is strong spiritual underpinning to this system. The TC's emphasis on positive values or the pursuit of "right living," has implications not only in terms of better mental health but also in the sense of being a morally upright person. In the past, addiction or the "pleasure-seeking vice" was associated with "evil nature," "moral bankruptcy," "moral weakness," or "the disease of the soul." Recovery was also related to walking away from sinful life, penance, denying physical pleasure, mortification of the body, and attaining self-realization through "righful living." The association between recovery and religious awareness or insight stuck. Past religious movements such as the Washingtonians or the Oxford Groups or the Alcoholics Anonymous emphasized the importance of religious awareness or spiritual awakening as being intimately related to sobriety. The closest parallel to these experiences within the TC experience is in the dimension of personal change or growth, which involves a significant shift in values and outlook and the pursuit of "right living." The constrast between the "morally bankrupt" addict lifestyle and the positive values and lifestyle of a recovered person is almost equivalent to the addict's sinful life and the sober person's clean and morally upright life.
How does the TC differ from the 12-Step program?
Both the TC and 12-Step program subscribe to the self-help approach to recovery. The two depart from each other in a fundametal way over the view on whether addiction is a disease or not. Twelve-Step programs believe that addicts or alcoholics can remain on remission indefinitely but will be unable to rid themselves of the disease of addiction or alcoholism permanently. The TC, on the other hand, believes that a person can fully recover from addiction through a change process that involves behavioral, psychological or cognitive, social and moral aspects of himself, and a lifetime pursuit of "right living."
Does individual counseling has a place in the TC since it relies on "community as the primary" means of personal change?
Individual counseling has an important role to play as a therapeutic intervention in the TC. The problem lies in the way it is employed when counselors or mental health personnel used it to foster clinical relationships in exclusion of the community, or when counselors avoid or ignore its clinical value completely. Individual counseling in the TC must be focused on helping residents practice self-disclosure and obtain emotional support when revealing difficult and sensitive issues that are easier to discuss one-on-one at first. When individual counseling is employed to increase motivation and lead the person to greater integration into the community, it compliments all other TC therapeutic processes designed to help a resident use the community to meet his needs.
The display of strong emotions during encounter groups in TC might be too strong for many cultures that avoid public display of negative or strong emotions.
Encounter groups as practiced in TCs in the West, often involve public display of strong negative emotions. The TC, which tolerates adaptive external demonstrations of strong feelings, recognizes that basic emotions such as anger or hostilities or rage, resentment, frustations, fear, etc. are often tumultuous and unpleasant and must be vented appropriately without causing harm on the person and others. In the early phases of treatment the use of raw language as vehicle of negative feelings during encounter groups is tolerated, provided such language is not demeaning and does not violate personal dignity. When a TC is able to create an environment that is safe and emotionally supportive, residents tend to express their feelings in the encounter group without much inhibitions and fear of retributions. TC residents in various cultural settings eventually learn that honest expression of feelings in the encounter group is not intended to offend but a means of learning how to deal with emotions that otherwise would be self-destructive to suppress. Part of the TC culture is a tacit understanding among members that one should be emotionally honest toward one's peers and to express one's true feelings edequately in appropriate situations.
Synanon was a cult that fell in infamy for its abuses on some members and harassment of its enemies. How could the TC, which claims to be a humane approach, trace its origin to Synanon?
Synanon did not start as a cult and had a sound social structure and treatment philosophy. The methods were developed by its pioneers based on clinical intuitions that met the real needs of the addict. The Synanon approach to addiction in the late '50's and early '60's was based on sound premise borne of the years of experiences of the early ex-addict pioneers of the TC. The second generation TC's that followed Synanon had patterned their drug programs after Synanon when it was at its peak of its creative development and its reputation was yet untarnished. The break from Synanon by most of these spin off TCs occured when Synanon took a very different path that diverged from its original mission of saving the lives of the street and criminal addicts. While Synanon chose to close itself from the outside world, as its leadership became increasingly isolated and fanatical, the new and emerging TCs pursued Synanon's original goal of treating addicts and returning them back to society as productive members. The second generation TCs took on the task of developing further the methods and treatment philosophy started at Synanon. But most importantly, they took the necessary steps to avoid the tragic mistake that Synanon made.
How can one tell a genuine TC from those which are not?
An experienced TC practitioners will be able to tell through a thorough observation a genuine TC from those that are not because of their familiarity with the TC processes and how the TC methods work. TC experts agree that the necessary TC elements must be present to create a therapeutic environment. The most important distinguishing mark of the TC compared with other approaches to addiction is its emphasis on the "community as the method" for facilitating change. In other words, healing in the TC is mediated by the community processes as opposed to the specific intervention of a therapist. The community enjoins its members to a participatory process of self-help and mutual help among themselves.
How come some people who go through and complete the TC relapse to drugs or become addicted to other substances?
Treatment in the TC encompasses major psychological and social goals intended to help the recovering addict address behavioral, psychological, and cognitive deficits as well as learning adequate social and coping skills. During the addict's tenure in the TC, he engages in a social learning process and must exert the necessary efforts to achieve his treatemnt goals. In TC one gets back according to what he has put in. Since motivation varies, the less motivated spends more time in treatment and gets the benefits of treatment only as much as the amount of efforts he is willing to exert. Residents benefit from treatment according to his readiness, ability, and willingness to change. Therefore, some benefit much more than others, and are able to experience less set backs in reintegrating back to society. Undergoing the TC experience does not guarantee immunity from relapse to drugs or other substances. Because of the differences in psychosocial backgrounds and presenting issues and level of motivation for change, residents vary in their ability to deal with high-risk relapse factors. It is not uncommon that some residents go through the TC more than once before learning adequate skills to fend off relapse and remain steadfast in staying drug free.
