Therapeutic Communities Essay

Although the model of drug misuse treatment called the “therapeutic community” (TC) traces its American roots to Synanon, it has quite an ancient pedigree. At the dawn of the Christian era, Philo Judaeus wrote of communitae therapeutrides, the art of which was to “heal the souls which are under the mastery of terrible… incurable diseases of pleasures and appetites…. “

Thus, it appears that the struggle with uncontrolled appetite was a challenge then, as it is now, and the ancients embraced similar principles to ensure spiritual health. These 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. They can be summarized as follows:

  • 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
  • Leadership by elders—by models

In the 17th and 18th centuries, religion-based mutual help societies emerged in Western Europe.

Responding to the widespread overuse of alcohol, they launched temperance efforts in Europe that 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, including disclosure (confession), admonition, commitment, and conversion of others, spread and, by the 1800s, influenced development of the Oxford Groups.

The term therapeutic community, however, does not reemerge until World War II. At Northfield Hospital in England, a facility dedicated to the treatment of traumatized United Kingdom troops, two psychiatric innovators, Maxwell Jones and Tom Maine, sought to reapportion authority and decision making between staff and patients. They called their effort a “therapeutic community,” and “patients” in their psychiatric units became the active decision makers, taking on increasing responsibility for ward management. Early discussions among these pioneers resulted in five basic assumptions: (1) two-way communication at all levels; (2) decision making at all levels; (3) shared leadership; (4) consensus in decision making; and (5) social learning by social interaction with emphasis on the here and now. This horizontal, open system of communication was itself assumed to result in healing, eliminating the need for individualized treatment plans. This notion would later become doctrine in U.S. drug treatment TCs.

But the drug treatment TC was not introduced by any of the nurses or psychiatrists who, inspired by Jones, sought to develop similar models. It emerged in Venice Beach, California, in 1959, when an Alcoholics Anonymous member, Charles Dederich, began an organization called Synanon, embodying the mutual help principles of AA and characterized by hierarchical structure, a semi-open communication system, small-group encounters focusing on behavior change, and encouraging members or residents to become leaders. This clear progenitor of what later became known as TCs enjoyed early success working with heroin users, but it is best known for its slow decline into a controversial cult.

The next major residential community to utilize similar techniques for drug treatment was Daytop Village, established in New York in 1963. While adopting the treatment strategies of Synanon, this organization rejected that group’s notion of becoming an alternative, utopian community, referring to itself originally as a “humanizing community.”

In 1966, New York City’s mayor, John V. Lindsay, recruited Efren Ramirez, M.D., a San Juan psychiatrist, to coordinate the city’s narcotic treatment programs. Ramirez had already developed systems of community engagement, protracted client induction processes, and treatment approaches similar to those of Daytop Village. Daytop staff became a resource for Ramirez as he set out to expand the city’s response to a growing heroin epidemic. It was Ramirez, trained in the Jones model, who persuaded Daytop to use the term therapeutic community to describe itself.

Ramirez was soon joined by Mitchell S. Rosenthal, M.D., who had headed an alcohol and drug treatment unit at the U.S. Naval Hospital in Oakland, California, where he had introduced many structural and group characteristics of Synanon. Ultimately, Ramirez made Rosenthal his deputy commissioner for treatment.

The convergence shaped by Ramirez became a major force for expanding the TC model in New York City. Daytop lent staff to each of the treatment leaders in Ramirez’s group. This rich mix led to the development of Odyssey House (Judy Densen Gerber), Phoenix House (Rosenthal) and the expansion of Samaritan (Richard Pruss). By the end of 1968, Daytop staff had also contributed to a second wave of TC development with Gateway in Chicago, Gaudenzia in Philadelphia, and the Village in Miami.

Further expansion followed: Marathon House in New England, Integrity in New Jersey, Walden House in San Francisco, the Mendocino Family, and Abraxas. Participation in marathon therapy as TC training in authenticity, expiation, and commitment inspired many visitors to the Intensive Training Institute, developed at Daytop’s Swan Lake facility, to emulate part, or all, of this early TC model.

Subsequently, TCs spread to Sweden, Germany, and Great Britain. By the mid-1970s, the World Federation, led by Msgr. W. B. O’Brien of Daytop, had started programs in Italy, the Netherlands, and Southeast Asia, which, in turn, influenced further expansion into Spain, Portugal, and Brazil.

During the 1960s, leading researchers, such as O. Hobart Mowrer and Abraham H. Maslow, applauded early TC initiatives and contributed ideas as well as methods. At the start of the 1970s, outcome and follow-up studies done at Phoenix House by George DeLeon and others provided an academic and research base to the movement, bringing increased credibility and recognition.

By the end of 1974, 15,000 persons were being treated in TCs. In 1976, a Therapeutic Communities of America (TCA) planning conference sponsored by the National Institute on Drug Abuse (NIDA) brought first, second, and third wave post-Synanon groups together. Discussions focused on such issues as size, fidelity, working with various different populations, and the discreet needs of women with children.

In the 1980s, training in drug abuse treatment methods, supported by the U.S. State Department, brought the TC to Southeast Asia, South Asia, and East Central Europe. TCs were developed in Slovakia, the Czech Republic, Hungary, Slovenia, and Poland. The TC approach is now found not only throughout the Americas, but also in such Muslim countries as Malaysia, Afghanistan, Pakistan, and Bangladesh and in Lebanon, Israel, China, South Africa, India, Thailand, Vietnam, and Cambodia.

Key enduring principles have survived, along with certain features of program structure, daily schedule, small-group work, and the development of social responsibility and compassion. In most programs, the role of the leader—regardless of the size of the unit, program, or system—still influences what principles are emphasized or downplayed, although many European programs and some American ones have adopted a far more egalitarian Jones-like approach.

Not so curiously, the older leadership bemoans many current practices, the dilution or drift from earlier models. Newer practitioners, educated more broadly and with less doctrinaire backgrounds, applaud the utilization of new science-driven practices. To remain relevant, the movement must applaud history, use the key enduring principles, and also embrace new practices. It is no longer a belief system with some techniques found wanting, or at worst destructive. It is and can proudly refer to itself as a model of value, proven in the treatment of addictive disorders, and capable of developing character and survival competencies for many, regardless of the culture in which it is found.

Bibliography:

  1. Jones, Maxwell. 1953. The Therapeutic Community: A New Treatment Method in Psychiatry. New York: Basic Books.
  2. Knibb, Michael A. 1987. The Qumran Community. Cambridge Commentaries on Writings of the Jewish and Christian World 200 BC to AD 200, Vol. II. Cambridge, England: Cambridge University Press.
  3. McNeill, John T. 1951. History of the Cure of Souls. New York: Harper & Brothers.
  4. White, William L. 1998. Slaying the Dragon. Bloomington, IL: Chestnut Health Systems.

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