Therapeutic communities (TCs) have been recognized as one of the most important and widespread approaches to the treatment and cure of alcohol or drug abuse.
Actually TCs have changed a lot over time.
TC for drug addicts was born in the USA, in Santa Monica, California in 1958
(but there is also the isolated episode of
Kuitpo, TC for alcoholics in Australia 1945 which has left no history);
The founder was Charles Dederich, an ex-alcoholic, entrepreneur. He took from his experience at Alcoholics Anonymous (AA) both the principle of individual responsibility in bringing about a change in life, and that of mutual help.
The Community states that the philosophy of mutual aid defines the addiTCed person solely responsible for his own addiction: “«Was it you a stick the needle in your arm, you who put alcohol or drugs in your mouth" and "You alone you can do it, but you can't do it alone." Kooyman (1972).
The TC is Synanon (one of the many Californian Families of the time) was the inspiration for almost all the TCs operating today, even if many do not know it or have difficulty accepting these origins.
Synanon is community of life, or even a seTC. Each resident could choose to stay for life, becoming part of the "family".
The team within this TC was made up of people who had finished the personal recovery process without any kind of course or training; they act as an example for hospitalized people who could then in turn become members of the work team.
From Synanon then was born in 1963 in New York, the Daytop Village.
Psychiatrist and psychoanalyst David Casriel is the founder, together with a group of ex-heroin addicts.
This TC already showed some differences compared to Synanon's experience: first of all, it had been founded by a professional and the team was not made up only of ex-residents, who in this case had completed training in the treatment of addictions: the first operator was a sociologist.
TC is a first hint and example of a multidisciplinary team.
Thirdly, the mission changes: Daytop set itself the goal of social reintegration, giving particular importance to researching and recovering those skills and abilities previously compromised by lifestyle.
The experiences of Synanon and Daytop Village became a reference model for the subsequent TC which, from that moment on, developed like wildfire in America, Europe and Asia.
TCs followed the self-help and drug-free philosophy; no pharmacological was yet contemplated.
Almost in the same years, the concept of TC for adult psychiatric patients was formed in Europe: a group of people who come together with a common purpose and who possess a strong motivation to bring about a change in terms of individual growth and as a process social
In 1964 Maxwell Jones and colleagues in England began using the TC approach to treat
psychiatric patients at Belmont Hospital, as a way of making the treatment of
patients a social and democratic process (Jones, 1979). The general ideas that
formed the therapeutic environment of the psychiatric TC are similar to those
later used in TCs for the treatment of drug abuse (De Leon, 2000). Despite this,
TCs for treatment of substance abuse developed independently of psychiatric
TCs (Jones, 1979; Kaplan & Broekaert, 2003).
Over the years, TCs have had to modify their own
approach and its own model in order to better respond to the diversity of environments e
of the populations with which they are confronted.
In 1977, during the II TC International Congress in Montreal (Canada), Don Mario Picchi (founder of Ceis) began collaborating with the Daytop Village in New York from which Progetto Uomo descends in Italy and in many European countries, especially in the south Europe.
The roots of Progetto Uomo come from the meeting of the values and style of Volunteering, therefore from the concert of Self-Help mediated by the AA, Synanon with the methodology of the TC (Daytop Village) and with the ideas on Social Learning and the Therapeutic Community Democrat by Maxwell Jones.
There has been a gradual, but substantial, trend towards integration between the common characteristics of the American drug-free hierarchical model and the older English democratic model à la 'Jones
The primary difference between the TC and other drug treatment programs is the TC view that the community acts as the primary therapist and teacher (De Leon, 2000; Jainchill, 2000).
The community as a whole is able to take on the role of therapist and teacher in part because there is no expert/patient dichotomy (Deitch, 1997).
Community life is seen as the instrument through which individual change takes place (De Leon, 2000).
Giving residents a feeling of responsibility for their condition and progress allows them to discover their ability to choose a lifestyle and abandon the belief that they are viTCim of their disorder (De Leon, 2000).
The TC uses community as a method in order to provide individuals with an environment in which they can learn to change themselves. One aspect of TC life that supports personal change is the positive and negative feedback residents continuously provide each another as they react to one another. Residents, who are responsible for providing each other with feedback, do so out of responsible concern for one another. Because the TC is a safe family-like environment, residents are able to continually learn from each other through trial and error
Working, learning, and socializing with other community members provides different contexts in which residents must learn to adjust their behaviors, attitudes, and emotions (De Leon, 2000).
Disclosing personal thoughts and feelings is encouraged and seen as an
important aspect of both the individual’s and other residents’ recovery process.
Nielsen and Scarpitti (1997) developed a comprehensive framework of the global
and individual change process. The areas of global change include behavioral
change, dealing with core issues, increasing self-esteem, changing identity,
developing hope and belief in recovery, and developing motivation to live drug-free.
The individual changes include developing trust and recognizing changes in
one’s self.
Residents believe that the self-understanding they had acquired, what they had learned from inter-personal actions, and the experience of self disclosure were the most important aspects of their treatment (Van den Langenberg & Dekker, 1989).
But what is meant by recovery? A process of change through which individuals improve their health and well-being, live independent lives, and strive to achieve the full expression of their resources. SAMHSA 2011
Professionals and patients interact in a structured way to influence attitudes, perceptions and behaviors, especially those related to substance use.
TC uses a hierarchical way of functioning. Hierarchical value gradients sanction a scale of progressive individual and social responsibility.
The peer relationship is used on several levels. In particular, through group work, it serves the assisted to learn and introject social rules and to develop social coping skills.
The therapeutic clinical approach usually focuses on gathering, understanding and attacking negative thought patterns and dysfunctional behaviors. Their change requires individual and group therapies and community life itself.
The rules of conduct are underlined by the system of rewards and punishments aimed at improving self-control and increasing the sense of responsibility.
“A TC is a drug-free environment in which people with drug addiction (and other problems) live together in an organized and struTCured way with the aim of promoting change and making drug-free life possible once they reintegrate into society”, The TC gives life to a miniature society in which residents and operational staff play the role of facilitators of change. They play different roles and clearly adhere to the rules that have been designed to promote the process of change of the residents” Ottenberg (1993).
Over time, TC has diversified its products, learning not only to deal with subjects with problems other than drug addiction, but developing network, preventive and rehabilitative potential.
Each resident needed different treatments, different attentions, different programs.
Between the 70s and 80s people began to talk about the phenomenon of dual diagnosis "(...) simultaneous presence in the same subjects of psychiatric disorders and problems related to substance abuse and dependences.”
Then came the TCs for psychiatric patients, prisoners, for people with HIV, for marginalized people, for mothers-children, for adolescents, for people with eating disorders, TCs for observation-diagnosis, TCs for detoxification, TC for Crisis centres… .,.
Community is not a simple approach, community is family, it is acceptance, it is relationship, it is confrontation and conflict, it is support, it is a break and, unfortunately often, it is a response to loneliness and survival. The community is a "protected" place, where the growth path of the person moves constantly in and through everyday life
But TC is a garrison inserted in a wider system of care.
The network connects the solutions to the patient's life contexts (and her environment) and follows the patient in the various stages of the disease according to the principle of clinical appropriateness.
For its proper functioning, the network requires internal harmony and coordination.
An effective system of services requires a spectrum of care, from general care (for example, housing, general clinical services and social assistance) to those based on structured intensive therapeutic programs to semi-residential or residential or inpatient care.
Supply chains imply a continuum of care, where individuals can move up or down the four supply chains to access the most appropriate service.
A therapeutic path is like an integrated way of care; a therapeutic pathway is a multidisciplinary program that identifies the different needs and the expeTCed results of its various phases.
TC is part of it.
The aim of the treatment is to promote knowledge of oneself, of one's personal problems and of life in society and therefore to facilitate the change in the personal ability to live, to relate, to love and to work.
Many guests of the TC suffer from personality disorders or even more problematic psychiatric forms, have had traumatic life experiences that have resulted in serious states of suffering and drug use.
Patients who have not found help in other kinds of treatment may find advantage in a period of residential life, presumably between 12 and 24 months.
The program begins with an initial period of adjustment, of knowledge of the characteristics of community life and of knowledge by the therapeutic staff of the personal and family problems of the new guest.
The therapeutic approach aims to integrate the following components:
- Pedagogical. Educate on how to behave with other people in society but above all that the person reaches a certain level of personal autonomy, changes their lifestyle by reducing the risks to physical and mental health;
- Sociological. Living within a small community is a particularly significant experience of coexistence because it requires relating to others and collaborating day after day.
- Psychological-Psychiatric. Address and manage the reasons that have caused discomfort and suffering. Treating emotional and mental disorders.
- Medical. For body care and related organic problems.
The goal is to try to alleviate the suffering of the residents, promoting their personal growth, through the experience of a period of life together. Attention is therefore directed to the importance of human relationships, responsibility and personal dignity in a social environment which can be a tool for directly experiencing a maturational experience and making it your own.
TC aims to help its residents develop cognitive, emotional and relational skills, in an open community environment that fosters personal skills in taking responsibility for one's life - past, present and future.
It is good to cultivate a realistic therapeutic ideal, based on a correTC assessment of the resources and difficulties of each resident person and to develop a social community that favors the well-being of its guests as much as possible, which reaTCivates a growth process through comparison with others.
There is therefore a need for a strong updating of the TCs with an investment in the training of its operators and in the promotion of the skills of those who have the leadership.
In order to pursue these objectives, there are some key values:
Try to alleviate any state of suffering, personal and interpersonal.
Have curiosity about individuals.
Promote participation and sharing so that everyone feels responsible for the life of the community.
Maintain constant attention to the atmosphere, to the climate within community coexistence, from small informal moments of daily life to institutional moments, such as those of therapeutic work in groups.
Cultivate a culture of welcoming and non-judgmental evaluation towards any kind of problem that may arise.
Encourage sincere dialogue between people, residents and operators.
Support the professional competence of the operators carried out with passion, the efforts of our guests.
Continuously encourage the good social functioning of residents,.
Encourage individual responsibility,
Recognise, appreciate and promote personal efforts.
Give great importance to human relationships;
Give respect to individual differences;
Fostering learning in a community life;
Pay close attention to the boundaries between individual choices and community requests.
References
AAVV, ANALISI DELLA CONGRUITÀ DEI PARAMETRI NELLE COMUNITÀ TERAPEUTICHE, (2023) Quaderni CNOP n.10 Luglio 2023
Nielsen A., Scarpitti F, Inciardi A, Integrating the therapeutic community and work release for drug-involved offenders. The CREST Program, J Subst Abuse Treat, 1996 Jul-Aug;13(4):349-58.
Van den Langenberg, S. J., & Dekker, J. J. (1989). What is "therapeutic" in the therapeutic community? International Journal of Therapeutic Communities, 10(2), 81–90.
Broekaert E. What future for the therapeutic community in the field of addiction? A view from Europe. Addiction. 2006;101(12):1677–1678
Coletti M., Grosso L., La comunità terapeutica; prefazione di Luigi Ciotti postfazione di Luigi Cancrini edizioni gruppo Abele 2011
De Leon G. e Zeigenfuss J.L., 1986 Therapeutic communities for addicton, Thomas Edition Springfield
De Leon G. (2000) The Therapeutic Community: Theory, Model, and Method, Springer
De Leon G. Is the therapeutic community an evidence-based treatment? What the evidence says. International Journal of Therapeutic Communities. 2010;31(2):104–128.
Ottenberg, D. J., Broekaert, E. and Kooyman, M. (1993), ‘What cannot be changed in a therapeutic community?’, in: Broekaert, E. and Van Hove, G. (eds.). Special Education Ghent 2: Therapeutic communities, vzw OOBC, Ghent, Belgium.
Palumbo, Dondi, Torrigiani, (2012), La comunità terapeutica, Erickson
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