What is a therapeutic community’s and what is their approach?

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The therapeutic community model is one used by most long-term residential rehabilitations facilities.  A modified version is also used in correctional facilities (where the members are essentially forced to be there, given their incarceration, as opposed to being in the community voluntarily.  The premise is that the community acts as the agent for change.

Therapeutic communities (TCs) are a common form of long-term residential treatment for substance use disorders (SUDs). Residential treatment for SUDs emerged in the late 1950s out of the self-help recovery movement, which included groups such as Alcoholics Anonymous. Some such groups evolved into self-supporting and democratically run residences to support abstinence and recovery from drug use(Sacks & Sacks, 2010). Examples have included community lodges, Oxford Houses, and TCs. The first TC was the Synanon residential rehabilitation community, founded in 1958 in California. During the 1960s, the first generation of TCs spread throughout areas of the United States, and today the TC approach (see “What is a Therapeutic Community’s Approach?“) has been adopted in more than 65 countries around the world (Bunt et al., 2008).

Historically, TCs have seen themselves as a mutual self-help alternative to medically oriented strategies to address addiction and most have not allowed program participants to use medications of any kind, including medications such as methadone (a long-acting opioid agonist medication shown to be effective in treating opioid addiction and pain) (De Leon, 2000; De Leon, 2015). Over the past 30 years, TCs’ attitudes toward medications have gradually evolved, reflecting changing social attitudes toward addiction treatment and the scientific recognition of addiction as a medical disorder (De Leon, 2000; De Leon, 2015; Vanderplasschen et al., 2013). A growing number of TCs now take a comprehensive approach to recovery by addressing participants’ other health issues in addition to their SUDs, incorporating comprehensive medical treatment (Smith, 2012)and supporting participants receiving medications for addiction treatment or for other psychiatric disorders (see “How Are Therapeutic Communities Adapting to the Current Environment?“). Many of today’s TCs are also offering shorter-term residential or outpatient day treatment (De Leon, 2012; De Leon & Wexler, 2009) in addition to long-term residential treatment.

TCs have also been adapted over time to address the treatment needs of different populations. During the 1990s, modified TCs emerged to treat people with co-occurring psychiatric disorders, homeless individuals, women, and adolescents (De Leon, 2010; Sacks et al., 2004b; Sacks et al., 2003; Sacks & Sacks, 2010; Jainchill et al., 2005) (see “How Do Therapeutic Communities Treat Populations with Special Needs?“). Also, as the proportion of offenders with SUDs rose during the same period, correctional institutions began incorporating in-prison TCs (often in separate housing units), and TCs are available for people re-entering society after prison with the goal of reducing both drug use and recidivism(Wexler & Prendergast, 2010) (see “How Are Therapeutic Communities Integrated into the Criminal Justice System?“).

Initially, TCs were run solely by peers in recovery. Over time and in response to the changing needs of participants, many TCs have begun incorporating professional staff with substance abuse counseling or mental health training, some of whom are also in recovery themselves. Today, programs often have medically trained professionals (e.g., psychiatrist consultants, nurses, and methadone specialists) as staff members, and most offer medical services on-site (Dye et al., 2012; Perfas & Spross, 2007). According to a national survey of these programs, more than half of TC staff members are in recovery (Dye et al., 2012), and many have earned certification in addiction counseling or bachelors- or masters-level degrees.

Therapeutic communities (TCs) have a recovery orientation, focusing on the whole person and overall lifestyle changes, not simply abstinence from drug use. This orientation acknowledges the chronic, relapsing nature of substance use disorders (SUDs) and holds the view that lapses are opportunities for learning (Vanderplasschen et al., 2013; De Leon, 2012). Recovery is seen as a gradual, ongoing process of cognitive change through clinical interventions, and it is expected that it will take time for program participants to advance through the stages of treatment, setting personal objectives along the way.

A recovery orientation is different from an acute-care model, which focuses on interrupting drug use and helping the patient attain abstinence during treatment episodes rather than overall lifestyle change (Vanderplasschen et al., 2013; De Leon, 2000; Sacks et al., 2008b; Perfas & Spross, 2007; De Leon, 2012). TCs encourage participants to examine their personal behavior to help them become more pro-social and to engage in “right living”—considered to be based on honesty, taking responsibility, hard work, and willingness to learn (De Leon, 2000; De Leon, 2015; Vanderplasschen et al., 2013; Vanderplasschen et al., 2014; Bunt et al., 2008; Dye et al., 2009). As program participants progress through the stages of recovery, they assume greater personal and social responsibilities in the community. The goal is for a TC participant to leave the program not only drug-free but also employed or in school or training. It is not uncommon for program participants to progress in their recovery to take on leadership and staff roles within the TC.

Following the concept of “community as method,” TCs use active participation in group living and activities to drive individual change and the attainment of therapeutic goals (Dye et al., 2009; Dye et al., 2012; Vanderplasschen et al., 2013; Vanderplasschen et al., 2014; Bunt et al., 2008). With an emphasis on social learning and mutual self-help, individual participants take on some of the responsibility for their peers’ recovery. This aid to others is seen as an important part of changing oneself (De Leon, 2000; De Leon, 2015; Sacks et al., 2012a).

Another implication of the recovery orientation is that it is recognized that people will need options for ongoing support once they complete residential treatment at the TC to promote a healthy drug-free lifestyle and help them avoid relapsing to drug use (Hendershot et al., 2011). Relapse prevention is a part of many addiction treatment programs, aiming to increase awareness and build coping skills both to reduce the likelihood or frequency of relapse and its severity if and when it does occur. As they move toward completion of a TC program, participants are aided in connecting with formal aftercare and self-help groups in the community. This approach is consistent with care coordination, a highly emphasized component of

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