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24 septiembre, 2019

Therapeutic communities: history, principles, recovery, stigma and reintegration

Rowdy Yates
President of European Federation of Therapeutics Communities (EFTC)


“Synanon is not drug treatment.  It’s a school where people learn to live right.  Stopping shooting dope is just a side-effect!”. Chuck Dederich, (founder of Synanon, the first TC), in conversation with Abraham Maslow


Early Recovery Fellowships
Some of the earliest examples of self-help mutual-aid fellowships for sobriety appeared among the Native American population (White, 2000), largely as a side-effect of a generalised movement to improve the lot of the indigenous population.  Kenekuk, the so- called Kickapoo prophet and Handsome Lake, a Seneca chief, both founded popular movements at the beginning of the 19th Century (White, 2000).  Both movements stressed the importance of recovery and sobriety, but as a tool to improve and sustain the cultural life of a people humiliated and disenfranchised by decades of white aggression and deceit (White & Whiters, 2005).

Both of these early movements, coming over 150 years before the establishment of Alcoholics Anonymous, (AA) recognized that simply stopping drinking was only a small part of the solution. What was required was a significant change in belief and behavior. Kenekuk railed against the high prevalence of domestic violence among the Kickapoo and Handsome Lake argued that the work of a sober Indian was to organize and restore the dignity and cultural self-belief of the ‘red man’ (White, 2000).

Subsequent mutual-aid peer-support fellowships: the Washingtonians in the mid-19th Century and the Emmanual Movement with their Jacoby Clubs in the early 20th, had almost completely disappeared by the time of the formation of Alcoholics Anonymous (AA); although in some cities, Jacoby Clubs co-existed with the new fellowshiop and even provided premises for early AA meetings.  What seems striking about these early recovery groups is the similarity of their insistence that stopping drinking alone was not enough to sustain recovery. What was required was a much more radical alteration in the former addict’s thinking about themselves and how they behaved toward others and the company they kept.

The Alcoholics Anonymous fellowship has been one of the most successful mutual aid groups and has spawned a number of parallel organizations, including Narcotics Anonymous, Gamblers Anonymous, and Cocaine Anonymous. They too have, from their earliest writings, discussed the concept of the “dry drunk”: the former drinker who continues to behave in ways that are unacceptable and that were the hallmark of their former drinking career (Mäkelä, 1996).

The roots of the modern drug-free therapeutic community (TC) movement lie in AA (De Leon 1997; Rawlings & Yates 2001; Broekaert et al 2006), which, in its turn, was the continuation of a long history of self-help recovery groups including the Washingtonians, the Jacoby Clubs and the Blue Cross (Fédération Internationale de la Croix-Bleue) (White 2000; Yates & Malloch 2010).  In its early years, the TC attracted the interest and support of many medical practitioners and academics and, in Europe in particular, this led to a merging of TC practice with the social psychiatry innovations of Jones, Laing, Clarke, Mandelbrote, Basaglia and others. This earlier European tradition of ‘democratic’ therapeutic communities within the developing social psychiatry tradition (Kennard 1983; Vandevelde 1999; Clarke 2003) both ensured the acceptance of the new addiction TCs and served to temper some of their more ‘anti-treatment’ attitudes (Kooyman 2001; Yates 2011; Ravndal 2003).  Indeed, in Europe, most addiction TCs were initially established by enthusiastic psychiatrists.

However, despite this apparent ready acceptance within addiction psychiatry circles, it is equally true that therapeutic communities – and the mutual-aid fellowships from which they sprang – have continued to be viewed with some suspicion by many within mainstream addiction treatment (Best 2010; Best, Harris & Strang 2000).  In part, this seems to be a natural consequence of a traditional, infection control-focused view of substance use disorders as a phenomenon to be managed and contained.  But in part also, it appears to stem from a concern that TCs have failed to establish evidential credentials in a field increasingly dominated by the demand for evidence-based treatments.

Proyecto Hombre

The Drug-Free Therapeutic Community

The drug-free therapeutic community, or ‘concept house’ began with Charles Dederich’s Synanon experiment in a derelict waterfront hotel in Santa Monica, California in 1958 (Rawlings and Yates 2001; Yablonsky 1965).  Whilst Synanon had grown out of Dederich’s experiences as a member of Alcoholics Anonymous for a number of years, he and his fellow-travellers had identified two critical elements missing from the 12-step program, which they felt were necessary for successful recovery from heroin addiction.  Firstly, since most of the heroin addicts they were dealing with had little experience of the work environment, they recognized that this particular group would need a more intensive intervention which combined therapy with a structured work program.

Secondly, they had grown increasingly restless at AA’s insistence on not challenging the individual’s own story, or ‘cross-talking’ as it was then termed.  Dederich and his fellow adventurers felt that there were numerous times when a fellow recoveree needed to be told, in no uncertain terms, that they were rationalizing their behavior or sugar-coating an unpalatable truth.  It was out of these two beliefs that Synanon developed as a hierarchical structured program revolving around the “Game”; an uninhibited maelstrom of verbal condemnation, insult and abuse, later to be rebadged by Carl Rogers as the “encounter group” (Yates 2003).

Outside the confines of psychiatric medicine, there was a long tradition within Western Europe of the use of small, self-governing communities; particularly in the treatment of so-called ‘maladjusted’ children.  Indeed, it is this work, focussing as it did upon therapeutic interventions with a resistant and anti-social group of young people, which offers the most compelling precursor for the American therapeutic community model imported into Europe in the early 1970s.  Early examples include August Aichhorn’s, work with inmates in a Viennese juvenile prison, Homer Lane’s Little Commonwealth in the early part of the 20th Century and David Wills’ Hawkspur Experiment between the two World Wars.  These developments alongside the groundbreaking work of Steiner, Montesori, Pestalozzi and others – a mixture of tough love, extensive self government and hard manual labour (Bridgeland, 1971) – established a strong European tradition of confrontative groupwork and self-governance with young delinquents and facilitated the establishment of the early addiction TCs, as they began to be imported into Europe in the early 1970s and ensured that these apparently new ideas were accepted more readily than might otherwise have been the case.


Community as Method

At the heart of the therapeutic community modality lies the careful balancing of two complementary, but polar opposite elements.  Firstly, the TC is characterised by it’s use of the community itself, in creating a day-to-day environment which is designed to aid recovery and learning.  De Leon notes:

“What distinguishes the TC from other treatment approaches and other communities is the purposive use of the peer community to facilitate social and psychological change in individuals”. De Leon, 1997: 5


Thus, the daily routine and structure is manipulated in order to ensure that each member of the community is presented with appropriate and relevant challenges and rewards.  A therapeutic environment is not necessarily the same as a supportive one, although challenges must be set in a community within which, each individual feels safe and cared for.

Secondly, the rigidity and daily pressure of the work routine is counterbalanced by the use of groups where the hierarchy is abandoned and the rules and ideology can be challenged.  This encounter or resolution group system provides the safety valve to the ‘pressure cooker’ of ‘being on the floor’.

This careful juxtapositioning of two opposing elements is at the core of the early success of therapeutic communities.  Indeed, this balance between a retaining and supportive structure and the provision of a safe haven within which to explore and share experiences of personal vulnerability are seen as central to recovery oriented interventions in general (Best et al 2010; Jason et al 2006; White 2008).  The central tenet of the TC is that it is the day-to-day environment which constitutes the therapeutic input.  Formal interventions such as groups, merely allow release, understanding and goal-setting.  Creating a working environment which is pressurised, rigorous and often stressful, is a priority and should be recognized as a crucial element in the process.

TCs occupy a middle ground between mutual-aid fellowships and mainstream ‘clinical’ treatment. The peer-support and role-modeling elements of mutual-aid fellowships are central to the TC process.  The reward and punishment aspects of the resident hierarchy are in many ways similar to – and used in similar ways to – the 12 steps.  What is different in the TC model is the intensity of the intervention and the use of challenge and confrontation to point out unacceptable behavior and attitudes.  Whilst the use of confrontation has been questioned by White and Miller (2007), De Leon (2000) has argued that it is central to the recovery process and Jason and colleagues (2006), reporting on a 15 year study of the Oxford House movement, argues that sober-house residents were broadly positive about confrontation and challenge and saw it as an important resource in maintaining their recovery.


Recovery, Reintegration and Stigma

With the current pressure on TCs to foreshorten programme length (often in direct denial of scientific evidence regarding the relationship between programme length and effectiveness) it is clear that the TC will need to do two things much better in the future.  Firstly, it must begin to argue much more robustly that its categorisation as an expensive treatment (and therefore a treatment of last resort) is scientifically unsound.  It is this false belief in a lack of cost-effectiveness which drives the presssure for shorter (and less effective) programmes.

Secondly, since the first objective is clearly a long-term project, TCs will need in the short term to concentrate on the business of making post-programme reintegration more effective.  In part, this can be done within programmes by encouraging positive peer group bonding, facilitating the renewal and repair of pre-addiction familial and social networks and ensuring improved employability.

However, these interventions can only provide a limited support post-programme and TCs should also be working to promote positive images of recovery and the recovered.  Many TC graduates will find at least some areas of employment closed to them regardless of their ability.  This sort of stigma has been extensively reported (Singleton, 2011) and is one of the most negative impacts upon long-term recovery.  In part, this ongoing stigma has its roots in a widespread belief in addiction as an ‘incurable disease’; a belief which is, of course partly reinforced by both the mutual-aid fellowships and the proponents of long-term methadone prescribing.  But the public can be persuaded to change its views on such issues and there can be little doubt that there is a vital role for TCs in the coming years to promote and celebrate recovery as part of this campaign.

 Proyecto Hombre




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[1] An earlier, more detailed version of this paper was published in Journal of Groups in Addiction and Recovery in 2011, (6[1/2], pp. 101-116).

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