Therapeutic Community

Introduction

• The therapeutic community (TC) for the treatment of drug abuse and addiction has existed for about 40 years.
• TCs are drug-free residential settings that use a hierarchical model with treatment stages that reflect increased levels of personal and social responsibility.
• The goals are to effect a complete change of lifestyle, including abstinence from substances, to develop a personal honesty, responsibility and useful social skills and to eliminate antisocial attitudes and criminal behavior .

History

Under the influence of Maxwell Jones, Main, Wilmer and developed the  concept of the therapeutic community and its attenuated form - the therapeutic milieu - caught on and dominated the field of inpatient psychiatry throughout the 1960's. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other's mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. 'TC's have sometimes eschewed or limited medication in favour of group-based therapies.

 Definition

“A therapeutic community is a drug-free environment in which people with addictive (and other) problems live together in an organized and structured way in order to promote change and make possible a drug-free life in the outside society. The therapeutic community forms a miniature society in which residents, and staff in the role of facilitators, fulfill distinctive roles and adhere to clear rules, all designed to promote the transitional process of the residents” ( Ottenberg 1993)

Stuart and Sundeen defined therapeutic community as “a therapy in which patient’s social environment would be used to provide a therapeutic experience for the patient by involving him as an active participant in his own care and the daily problems of his community”.          

Objectives

• To use patient’s social environment to provide a therapeutic experience for him
• To enable the patient to be an active participant in his own care and become involved in daily activities of his own community
• To help patient to solve problems ,plan activities and to develop the necessary rules and regulations for the community
• To increase their independence and gain control over many of their own personal activities
• To enable the patient to become aware of how their behavior affects others

Elements of therapeutic community

• Free communication
  
• Shared responsibility
  
• Active participation
  
• Involvement in decision making
  
• Understanding of the roles ,responsibilities ,limitations and authorities
  

 Components of therapeutic community

 a) Daily community meetings

• These meetings are composed of 60-90 patients. All levels of unit staff are involved, including administrative personnel. Acute patients are not involved in the meetings.
• Meetings should be held regularly for 60 minutes
• Discussion should focus mainly on day to day life in the unit
• During discussion patients feelings and behaviors are examined by other members
• Frank discussion are encouraged ,these may take place with much out poring of emotions and anger

b) Patient Government or Ward council

• The purpose of patient government is to deal with practical unit details such as house-keeping functions, activity planning and privileges
• A group of 5-6 patients will have specific responsibilities, such as house keeping, physical exercise, personal hygiene, meal distribution, a group to observe suicidal patients. Staff  members should be always available
• All decisions should be feedback to the community through the community meetings

c) Staff meetings or Review

•  A staff meeting should be held following each community meeting (patients are excluded and only staff are present). In this meeting the staff would examine their own responses, expectations and prejudice.

 d) Living and learning opportunities

•  Learning opportunities are provided within the social milieu, which should provide realistic learning experiences for the patients.

Length of treatment in a therapeutic community

In general, individuals progress through drug addiction treatment at varying speeds, so there is no predetermined length of treatment. Those who complete treatment achieve the best outcomes, but even those who drop out may receive some benefit. Good outcomes from TC treatment are strongly related to treatment duration, which likely reflects benefits derived from the underlying treatment process. Individuals who complete at least 90 days of treatment in a TC have significantly better outcomes on average than those who stay for shorter periods.

Traditionally, stays in TCs have varied from 18 to 24 months. Recently, however, funding restrictions have forced many TCs to significantly reduce stays to 12 months or less and/or develop alternatives to the traditional residential model .For individuals with many serious problems (e.g., multiple drug addictions, criminal involvement, mental health disorders, and low employment), research again suggests that outcomes were better for those who received TC treatment for 90 days or more.

In the TC, the level of treatment engagement and participation is related to retention and outcomes. Treatment factors associated with increased retention include having a good relationship with one's counselor, being satisfied with the treatment, and attending education classes. Important attributes linked to treatment retention include self-esteem, attitudes and beliefs about oneself and one's future, and readiness and motivation for treatment. Retention can be improved through interventions to address these areas.

Structure of the therapeutic community

TCs are physically and programmatically designed to emphasize the experience of community within the residence. The residential capacity of TCs can vary widely; a typical program in a community-based setting accommodates 40 to 80 people. TCs are located in various settings, often determined by need, funding sources, and community tolerance. Some, for example, are situated on the grounds of former camps and ranches or in suburban houses. Others have been established in jails, prisons, and shelters. Larger agencies may support several facilities in different settings to meet various clinical and administrative needs.

The treatment process: therapy, education and training

The elements of treatment at the TC typically include substance abuse treatment, education (General Equivalency Diploma or, in some cases, university courses), primary medical and dental care, vocational skills training (e.g. culinary arts, carpentry, general maintenance, mechanical systems, general contracting, computer skills, or substance abuse counseling), on- and off-site job placement, and in rare cases, on-site resident-run businesses. Other supports include legal services, advocacy, and life skills counseling. There is no formal religious component to treatment, education or training. In fact, experts caution against the introduction of religion as an aspect of daily life in the TC .

TC treatment can be divided into three major stages.

Stage 1. Induction and early treatment : This phase typically occurs  during the first 30 days to assimilate the individual into the TC. Once the intake process of interviews and assessments is complete, new arrivals to the TC are often housed in rooms with six to eight bunkmates. It is generally expected that new residents must be medically detoxified prior to beginning the program. Leader who is responsible for the orientation of the new resident to the rules and expectations of the TC.

Work is often identified as one of the central components of the therapeutic approach. As such, job assignments or “functions” begin immediately for new residents, usually with basic housekeeping or maintenance chores. The work-centered approach is intended to serve multiple purposes.

• First, by beginning with general maintenance work,  the resident acquires knowledge of the facility’s physical layout and organizational structure.
• Second, daily work is believed to instil an ethic of discipline and hard work that is desirable according to the TC treatment model.
• Third, putting new residents to work immediately reinforces the broader nature of the TC as a structured, merit-based program, where residents earn privileges and seniority by complying with all rules and behavioural expectations. In this case, the implied goal for the new resident is to move up a strict hierarchy of jobs and departments to more desirable positions.
• Lastly, the work is often physically demanding, leaving residents physically tired at the end of the day so that they have no time to think about leaving and returning to their previous  lifestyle.

Progression from phase one to phase two is be made on the recommendation of staff members and, to a lesser extent, the broader peer group, and  is typically judged on the basis of the individual resident’s attitude, work competence and peer relations.

Stage 2. Primary treatment

In Phase two the resident is expected to take on more responsibility for the welfare of others, particularly newcomers. At this stage, he or she is normally introduced to three vocational training areas. Training takes place during the daytime hours, with expected  study time in the evening. Residents typically begin courses to improve literacy, develop  computer skills and achieve a General Equivalency Diploma (GED). Residents are also typically expected to continue with their encounter groups, with the goal of adopting positive beliefs and attitudes toward themselves and others. By the end of phase two,  residents are normally expected to have completed their GED, choose one vocation training area in which to specialize, participate in encounter groups, deal with more daily responsibility, and adhere to the rules and regulations of the facility. Often  uses a structured model of progression through increasing levels of prosocial attitudes, behaviors, and responsibilities. The TC may use interventions to change the individual's attitudes, perceptions, and behaviors related to drug use and to address the social, educational, vocational, familial, and psychological needs of the individual.

Stage 3

Entry into phase three normally begins when the resident has applied for, and has been accepted to train in a vocational area on a full-time basis, with the intention of completing a certificate in the program or trade, and finding related work outside of the facility after leaving. Residents may be reimbursed nominally for their vocational work. The money is saved so they will have money to begin their new lives once they exit the program. During this phase, residents may be encouraged to attend social activities outside of the facility accompanied by other members, as well as re-establish contact with their   families of origin. A family reunification program is sometimes established.

Stage 4. Re-entry At this point residents typically share accommodations and bathrooms with a smaller number of residents in a more home like setting. It is believed that by this phase, residents have acquired skills and coping abilities to allow them to “re-enter” society.These skills often include a GED, vocational training, computer literacy, and relationship and coping skills. If any money has been saved for the resident, these funds will be released with the expectation that a bank account will be opened for living expenses.

Staffing

TCs are often staffed by a carefully chosen group of professionals who receive training in the specifics of the TC model. Experts suggest that program staff should comprise a mix of self-help recovered professionals and other traditional professionals (e.g.  nurses, physicians, lawyers, case workers, counselors) 8). An average resident to staff ratio was cited as approximately 15:1.

Resident profile and special populations

 Many residents have been drug addicted for years and have a history of criminal activity or other legal problems. Other common factors include multi-generational poverty and homelessness. most TCs stipulate that residents must be healthy enough to undertake physical labor and participate in training programs and other group-related activities. Potential residents are generally deemed inadmissible in the case of a history of kidnapping, rape, arson, child molestation, suicide attempts.

The screening and intake process for TC residents is rigorous, typically involving an initial visit or phone call, admission to a waiting list, an orientation process, one or more intake interviews, medical, legal and psychological assessments, and consent to treatment. A thorough intake process is considered to be particularly critical in light of the high rate of drop-out which commonly reaches 50% within the first 30 days.

The daily regimen

A typical TC day begins at 7 a.m. and ends at 11 p.m. and includes morning and evening house meetings, job assignments, groups, seminars, scheduled personal time, recreation, and individual counseling. As employment is considered an important element of successful participation in society, work is a distinctive component of the TC model.

In the TC, all activities and interpersonal and social interactions are considered important opportunities to facilitate individual change. These methods can be organized by their primary purpose, as follows:

• Clinical groups (e.g., encounter groups and retreats) use a variety of therapeutic approaches to address significant life problems.
• Community meetings (e.g., morning, daily house, and general meetings and seminars) review the goals, procedures, and functioning of the TC.
• Vocational and educational activities occur in group sessions and provide work, communication, and interpersonal skills training.
• Community and clinical management activities (e.g., privileges, disciplinary sanctions, security, and surveillance) maintain the physical and psychological safety of the environment and ensure that resident life is orderly and productive.

Advantages of therapeutic community

• Patient develops harmonious relationships with other members of the community
• Gains self –confidence
• Develops leadership skills
• Learns to understand and solve problems of self and others
• Becomes socio-centric
• Learns to live and think collectively with the members of the community
• It provides opportunity to participate in the formulation of hospital rules and regulations that affect patient’s personal liberties like bedtime, meal time, weekend permission, control of radio or T.V, social activities , late night privileges.

Disadvantages of therapeutic community

• Role blurring between staff and patient
  
• Group responsibility can easily become nobody’s responsibility
  
• Individual needs and concerns may not be met
  
• Patient find the transition to community difficult
  

Role of the nurse

• Providing and maintaining a safe and conflict free environment through role modeling and group leadership
  
• Sharing of responsibilities with patient
  
• Encouraging patient to participate in decision making functions
  
• Assisting patients to assume leadership roles
  
• Giving feedback
  
• Carrying out supervisory functions
  

 Conclusion

Several studies have found that this approach to treatment is successful in substantially improving the quality of life for members. A study of patients at the Cassel Hospital showed that 98% of patients are too disturbed on admission to find employment, but that five years later 90% have jobs. Re-admission and re-conviction rates have been found to drop considerably after treatment in a therapeutic community.

References

1. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry. 9th ed. Hong Kong :William and Wilkinson Publishers ;1998.
2. Dr. Bimla K. Text Book of Psychiatric Nursing vol. II. 1st ed. New Delhi: Kumar Publishing House; 2006
3. Sreevani R. A Guide to Mental Health and Psychiatric Nursing .New Delhi:Jaypee Brothers Medical Publishers;2006.

Posted in: Mental Health Nursing