A plethora of evidence indicates that the majority of those engaged in substance use treatment have histories of trauma and abuse. If treatment providers are moving towards a trauma-informed approach, why are Therapeutic Communities still in existence, funded by insurance, and not deemed wholly unethical and abusive? Does it not seem utterly counterproductive and cruel to further abuse those who have been abused?
A Brief History of the Therapeutic Community Model and Confrontation Practices
The Therapeutic Community (TC) model currently still operates in hospitals, prisons, juvenile detention centers, outpatient treatment programs, and a variance of other community treatment centers. The use of confrontational strategies in substance use treatment was originally practiced within voluntary peer-based communities, pre-dating reliable evaluation of treatment methodologies, and is now often legally mandated by the court system, and is predominantly used as an authority-based relationship with great potential for abuse and harm.
Dr. Harry Tiebout’s clinical observations of alcoholics in the 1940s and 1950’s led to the confrontational therapy movement in the treatment of alcoholism. Tiebout’s psychoanalytic perspective of the alcoholic contended that the alcoholism was deeply rooted in character malformation and ego inflation. He asserted that the alcoholic was incapable of an accurate perception of oneself due to a tangled web of defense mechanisms that justified the drinking and furthered grandiosity. Tiebout believed that authoritarian confrontation was the only method that could break down the pathological immaturity and egocentricity of the addict or alcoholic. He alleged that the family of the addict or alcoholic was “merely an aberrant, co-dependent personality, equally as pathological as their loved ones.” According to Teibout, the therapist’s only duty was to assist the alcoholic or addict in shifting from a superficial verbal compliance (and outward behavioral defiance) into a more disciplined personality restructuring, based on the principal of surrender. Tiebout’s famous aphorism, “Break ‘em down to build ‘em up,” was strongly influenced by his close association with Alcoholic Anonymous (AA). He contended that therapists could “hasten the alcoholic’s recovery process” by deflating the narcissistic encapsulation, confronting the faulty distortions directly, and moving the alcoholic in the direction of total surrender.
Charles Dederich, developed his own offshoot of AA in 1958, and developed Synanon-a self-supporting, peer-based recovery community. Dederich sought the need to modify AA’s program to incorporate members who also suffered from narcotic addiction, and add some non-standard practices of his own. Syanon shifted from a theology-basis to an ideological platform to gain adherents from the drug abusing population. Syanon merely changed content rather than form, and provided explicitly axiomatically framed beliefs to provide structure and meaning to the members who were thought to have “meaningless and chaotic lives, devoid or purpose.” Still heavily based in religion, Synanon viewed the field of psychiatry and medical community with grave suspicion, and only believed in complete and total abstinence and detoxing from substances “cold turkey.”
TC’s still contend that addiction is a psychosocial problem, not a medical one, and has strong aversion to the use of methadone and other medical treatments to treat addiction. Ignoring the growing body of evidence that substantiates the biological basis of substance use, TC’s view psychiatric issues and cravings for substances as part of the “addiction syndrome,” and believe that all psychiatric symptoms will be resolved once the person is clean and sober.
Syanon developed a vastly popular “game club” which can still be found in TC’s and is still referenced by “old timers” in twelve-step groups. Some of the games included forced confession that the member is stupid or a baby, and will ask the new member to surrender something of value (money, property, hair) to demonstrate their commitment to recovery. Other newcomer games included demands to change physical appearance and demeanor, being forced to wear a diaper, toilet seat or sign, or verbal ridicule that could span as long as eight hours. TC “graduates” could quickly move into staff positions to further advance their skillset. The most controversial and publicized programs were aimed at juveniles participating in diversion programs such as “Scared Straight” that were explicitly designed to demean and humiliate.
A Paradigm Shift
Therapeutic Communities and self-help programs constitute a treatment culture, which incudes a social ideology that reflects underlying values, beliefs, and assumptions about reality and normative practices. For many years these communities were free from funding regulations and medical guidelines, and became “culturally encapsulated.” Galanter termed these communities as a “therapeutic cult” and noted the gradual process toward ethnocentric monocultralism, and cult-like characteristics that seemingly devalue outsiders and assume an attitude of riteousness about their own customs and beliefs. TC’s and self-help groups are still inherently biased against the medical community, and employ the five components of ethnocentric monoculturalism today: Belief in superiority, belief in inferiority of others, the power to impose standards, manifestation in institutions, and an “invisible veil” which consists of unconscious values and beliefs that compromise the group’s worldview. After Synanon’s fall, the next generations of the TC movement grew closer to a more mainstream view, and ethnocentric monoculturalistic qualities began to fade.
Unfortunately, it is still not a common practice for clinical staff or counselors working in Therapeutic Communities to be adequately educated or trained to work with dual diagnoses or co-occurring conditions. Counselors primarily focus on eradicating problematic behaviors, thus eliminating the flexible perspective needed to employ a sensitive treatment modality.
A Healthy Approach
Psychologist, Carl Rogers, first introduced an empathetic and collaborative partnership with the client. Rogers believed that the therapeutic relationship is a partnership that fundamentally respects the client’s right to self-determination, and utilizes the client’s own motivations for positive change. Motivational Interviewing is another alternative to confrontational practices, and seeks to further the humanistic approach by manifesting an empathetic, respectful, and collaborative approach to substance use treatment. The Sanctuary Model is gaining popularity in the treatment field, and is a trauma-based approach that serves to normalize symptoms and behaviors, rather than pathologize. The Sanctuary Model stresses the concept of safety, in regard to personal and physical safety, psychological safety, social safety, and moral safety. The Sanctuary model changes the fundamental question to “What’s wrong with you?” to “What’s happened to you?” This position of connectedness and compassion rather than judgment, is a deep philosophical movement from the aforementioned treatment modalities that focus on the illness and deviance. Instead of viewing people as sick or bad, this model views disturbed behavior as a response to a previous injury that can be understood only by recognizing the total context and experience of the person.
In reviewing psychiatric literature from the past twenty years, one may conclude that the Therapeutic Community model of treatment has died an “untimely death.” While it is true that the TC model is slowly fading away, the long-term consequences of unresolved traumatic experience coupled with the disintegration of communities of meaning, encourages a new look at substance use treatment as a whole. Jules Henry begged the still-relevant question, “Cruelty has an institutional structure that sustains, teaches, and may even glorify it. But where are the institutions-the organizations-that sustain and teach tenderness?” Perhaps our patients who have suffered extraordinary measures at the hands of others can be the ones to teach us the most about individual and social healing, and how to change our institutions to reflect a more humanistic approach.