THE THERAPEUTIC COMMUNITY FOR
EX-ADDICTS: A VIEW FROM EUROPE.
Broekaert Eric (Ph. D.)1
Van der Straten Georges (Ma.)2
Franky D’oosterlinck. (Ma.)3
Martien Kooyman (M.D.)4
Submitted to “Therapeutic Communities: The international journal for Therapeutic and Supportive Organizations”.
1. Professor in Special Education, Department Special Education, University of Gent
2. Director of the Therapeutic Community ‘Trempoline’, Charleroi
3. Director of the Orthopedagogical Observatlion and Treatment Centre, Gent
4. Psychiatrist, Bonding Therapist, Rotterdam
ABSTRACT: The Therapeutic Community for Addicts originated in Europe during the seventies. It was influenced by the American self help movement, and tried to change the addicts life style through behaviour modification and confrontation with a value system reflecting responsibility and concern. In the beginning of the nineties the change towards current times became manifest in the drug field and the therapeutic community. After analysis and having determined “What cannot be changed in a therapeutic community”, the challenge was taken on. The following article analyses the main changes in the drug field. It aims at describing the major developments that led to the “new” therapeutic community. Much attention is given to the impact of professionalism and research, new target groups, networking and family involvement, and adaptation of therapeutic methods in favour of dialogue. It was concluded that the essential educational and therapeutic characteristics and the flexible approach of the therapeutic community led to it’s survival.
Therapeutic Communities (T.C.’s) for addicts - also called concept or hierarchical or drug-free T.C.’s - appeared in the seventies during a period in which “drugs” were considered an absolute danger which had to be combated. Their history and philosophy has often been described. (Broekaert, 1997) During the eighties they were able to stabilise their treatment and perfect their methods. In the 90’s everything pointed to a time of transition and this was concretely manifested in the field of drugs. Traditional moral and ethical principles were confronted with the sometimes radical ideas of a new generation of social workers, politicians and intellectuals. A broad spectrum of new developments came into being. (Broekaert, 1998) The first reaction was to stabilise the situation. On the initiative of D. Ottenberg (1) a group of European T.C. specialists gathered in “De Haan-Belgium” in order to find an answer to the question “What cannot be changed in a Therapeutic Community?” In 1993 C. Kaplan expounded the socio-historical evolution of modern to current society, as well as the consequences for drug policy development. (Kaplan, 1993)
CURRENT CHANGES IN THE FIELD OF DRUGS
Since the seventies many changes in drug abuse patterns, therapeutic approaches and typology of users have taken place. (Broekaert, van der Straten, 1997)
Those changes were discussed at the European Conferences of Therapeutic Communities. (Berlin, Germany, 1990; Stockholm, Sweden, 1993; Milano, Italy, 1994; Thessaloniki, Greece, 1995; Oslo, Norway, 1997).
We can summarise them as follows:
· The recreational use of cannabis as well as questions arising from the comparison of the legal status of alcohol and cannabis. This created an ambiguous area which was then exploited by many young people looking for excitement.
· The appearance of new “recreational” drugs such as XTC and smart drugs, used by many young people. The profile of these users and the gravity of the cases is apparently not directly comparable to the situation of heroin and cocaine addicts.
· The growth of petty delinquency linked to the trafficking of hard drugs, the inability of the police to enforce the law, and the over-crowding of law-courts and prisons, all led to unrest amongst the population who demanded that the government find a solution and restore social order.
· The limits of repression: the steady and uncontrollable growth of the numbers of young people and drugs which flooded the black market made clear the limits of repression.
· Risk-reducing programmes: one by one many countries initiated experimental programmes and looked for urgent solutions, from a medical or security perspective, to achieve better control and guidance over the tens of thousands of heroin users not motivated to change. These risk-reducing programmes which relied on substitutes were very popular. When the contradictions and limits inherent in these low-threshold programmes became apparent, new medical and pharmaceutical options were sought, such as the medical prescription of heroin.
· In the merciless social-economic climate of unemployment, of the liberality of the market, and of social exclusion, drugs are not so much a support in the fight against poverty and existential despair as a means of shining in a hedonistic society.
· New and brutal competition: the austere politics of government finances created a new situation for the T.C.’s.. The majority of new subsidies were invested in “low threshold” projects which reached more people and cost less than the T.C.’s. Compared to the maintenance programmes working with substitutes and to educators working on the streets, the T.C.’s appeared to be costly and inaccessible centres destined for a small minority.
· Dual diagnosis: Day-care and hospital services for addicts are confronted more and more with addicted patients who are also severely disturbed (dual diagnosis) and who require residential treatment in a place equipped to deal with drug abuse.
· Delinquent addicts: The law-courts continue to be flooded with files of drug abusers and prisons are over-populated with drug-dependant prisoners. There continue to be many addicts who turn to crime because of drugs, but a steadily increasing proportion of them consists of criminals who take drugs. In other words, an anti-social personality existed prior to the drug problem. About 50% of the heroïn addicts commited criminal acts before their first experience with drugs. In prison, where they lack the resources to deal with this problem, drugs are smuggled in and this contributes to a serious decline in the relationships between prisoners and with staff members.
THE ANSWER PROPOSED BY THE THERAPEUTIC COMMUNITY
During the seventies professionals and volunteers, assisted by American ex-residents of “Daytop Village” and “Phoenix House New York”, played an important role in the development of the European T.C. (Kooyman, 1993, p.18-21; O’Brien, 1984, p.12-17). Most professionals were psychiatrists, psychologists and social workers, but also priests. The majority had followed a training as a “resident”, spending a few months in a therapeutic community. As they knew each other fairly well, they formed a network of mutual assistance. In the South of Europe volunteers played a more prominent role.
In France, under the influence of psychoanalysis, there was much resistance towards the behaviourist “American” T.C. concept.
It is interesting to compare the above mentioned country national with the contribution of D. Kennard in Campling and Haigh (Campling and Haigh, 1999, pp.235-245) in which he largely describes the development of communities for people with mental disorders in Europe.
Throughout the eighties, the role of the professional became steadily more distinct. H. Hesta (Hesta, 1984, p.138-142) reported this ”change of concept from self-help to more professionalism”. He describes how the professionals appropriated the skills, and changed the system through the implementation of new therapeutic methods such as bonding, psycho-drama, pesso-motor therapy and so on. He also observed a growing professionalism among the ex-addicts. Ceasing to deny professionalism can provoke confusion and conflict but leads to an integration of behaviour modification (ex-addict’s) and to a psycho-dynamic approach towards personality (professionals). During the nineties these tendencies were not only stabilized but even strengthened. Complete integration in the clinical system increased the demand for staff members with a specific training in “addiction”. Much attention was given to training. In most countries national training centres were set up. In the nineties, university programmes such as “Erasmus” and “Socrates” started to influence the therapeutic communities. An innovative range of student centred, co-operative higher education and training programmes were promoted throughout European universities in close co-operation with the therapeutic communities. The “Modena institute” was created in 1995 as a common initiative of the Modena T.C., the European Federation of Therapeutic Communities (E.F.T.C.) and the University of Gent joined in a Socrates project with Italian, Spanish, Portuguese, Scottish, Dutch and Swedish universities. It organised effective training for about one hundred students and staff, and continues its activities. Some of these led to new initiatives in which training efforts are combined with new learning technology such as long distance teaching and video conferences. The effects of this professionalisation gradually led to better understanding and to the application of some of the democratic principles of the democratic/analytic T.C.. Even if the term “analytic” is often associated with “looking for excuses in the past”, there can be no doubt that the influence of people such as Maxwell Jones and Harold Bridger was of real importance. During many World and European conferences and meetings they explained the essence of their thought. Bridger was convincing in explaining the importance of transitional space and the global approach. Jones (1984, pp.29-35) principle of “social learning” is now considered one of the cornerstones of the drugfree T.C.. In addition we should not forget that Dan Casriels’ theory on the frozen personality structure of addicts was analytical in origin. Most of all, however, the majority of European T.C.’s dispensed with the humiliating signs and learning experiences that so strongly resembled an authoritative stimulus response approach.
The network and family-orientated approach
A hierarchic structure and confrontational encounter groups typified the early T.C.’s. As well as the community itself, there was also a reception centre and a half-way house for social reintegration. Little attention was given to working with families. Following a plea from Bridger of the “Tavistock”-group to conceive of a T.C. as an open system, and following the innovative approach of M. Picchi and J. Corelli who developed a new structure strongly favouring family participation, an opening was gradually created. (Bridger, 1984, pp.54-70; Picchi, 1994, pp.5-81) . Many T.C.’s. came to consider family involvement as an integral part of their approach. They did not adhere to any one school of thought but selected elements from various schools depending on the possibilities and resources of their teams. These elements were then integrated into the therapeutic and educational concept of the T.C.’s without too much concern for orthodoxy. They preferred a pragmatic system which allowed them to adopt any principle which would help the residents overcome their problems. Since 1978 many Spanish and Italian T.C.’s have used the term “family collaboration” (coinvolgimento familiare) as against “family therapy” (terapia familiare parallela). This was an initiative of the “Centro Italjano di solidarita” of Rome as part of their model “Progretto Uomo” (project human being). Their programme consist of three phases: Acceptance – Treatment - Insertion, in which the family plays an important part. It is not their aim to “cure” the families in question, but rather to exploit their resources in order to more effectively help their addicted child. They wanted to make a clear distinction between classic system based family therapy and their concept-based self-help programme. They maintain that one should not confuse a “family in crisis” with a “sick family”. The majority of families are not ill, but are faced with a problematic situation which they cannot resolve. As with the residents themselves, family dynamics involve learning and development as against pathology and treatment. This approach adopted by 40 programmes in Italy and as many in Portugal and Spain. The capacity of the programmes varies enormously: between 100 and 1000 people divided into sub-groups ranging from 30 to 100 participants. Clearly there is no discrepancy between a family-orientated approach and the educational and therapeutic concept of the T.C.’s.. The T.C. is essentially an educational system in which family therapy can be integrated as an element essential to the good functioning of the T.C. (Cogo, In: Broekaert et.al., 1996, pp. 77-85). Hand in hand with these innovations in the family area, the T.C.’s started to define themselves as a very diverse network of applications known as the “new T.C.”. Various centres gradually became complex networks of interaction, and subsequently expanded their methods in order to reach different structures and target groups: T.C.’s for addicted mothers with children, psychiatric patients, children and adolescents with behavioural problems, immigrants and the homeless. Certain T.C. detoxification centres, which controlled the administration of methadone, started vocational schools and founded training centres. (De Leon, 1997) The units function independently but are linked to the other parts of the programme through the same fundamental concepts. G. De Leon calls this link “The community as a method”. Clearly the T.C.’s have understood the importance of taking the whole environment into consideration. Differentiation on the one hand, and the link with the complex whole on the other, determines the “new T.C.”. The global T.C. differs from models which perceive reality in parts. Should the T.C.’s profile themselves as a “school”, they would risk losing their identity.
Encounter and dialogue groups
In the first T.C.’s, encounter groups were described as “a total expression of the whole range of human emotion.” Residents challenged each other’s behaviour without fear and without inhibition. In the course of these confrontations, the pressure and stress broke down the barriers preventing the expression of emotion. This enabled each person to express their emotional problems in the “here and now”, which in turn enabled other residents to identify with the issues being struggled with, and gave new residents the chance to discover how problems could be dealt with and resolved. The purpose of this was not to seek explanation or comprehension, but to learn to change one’s behaviour and assume responsibility. There was no need to look for excuses in the past to justify present irresponsible behaviour. However this did not prevent the expression of past problems – on the contrary, this was frequently the outcome. Repressed emotions connected with early experiences were often expressed in a very direct and emotional manner (screamed or shouted), whereupon the person confronted was just as quick to defend himself. Group participants were not supposed to support the person confronted, since this would not teach them to assume responsibility for their own behaviour. On the contrary, the participants often confirmed the content of the confrontations and added further observations of their own. In fact participants were often confronting their own negative behaviour which they recognised in the other person. It is worth noting that group relationships had to be re-established after the confrontation between two persons.
Encounter groups were often classified with behavioural techniques, as many considered that straightforward conditioning was the sole target (Bratter, 1985, p..461-508). B. Sugerman describes the functions served by “Daytop groups” as follows: first, they provide a legitimate and carefully regulated outlet for verbal hostility and aggression which the strict rules of the house do not permit to be expressed at any other time; second the groups are the setting for an immense “reality therapy” in which a person is forced to listen to others telling him how they see him behaving, pointing out how certain problems of which he complains are the result of his own behaviour, and confronting him with how he feels about himself.” A.H. Maslow also gives us a accurate picture (Maslow, 1967, p.28-29) and, after his visit to Daytop, no longer doubted their humanity: “I received many impressions which I would express as follows: how can this right to honesty, towards and against everything, this hardness which often sounds like cruelty, furnish a basis for security, affection and respect? It hurts, and it has to hurt… I think it is possible that this brutal honesty implies a kind of respect, as against insult. And this can be a basis for respect and friendship.“ Maslow accepted beyond the shadow of a doubt that the existential and human aspect could be reached via behaviour. The goal of confrontation being to reveal the feelings and needs underlying behaviour, it is possible to focus on the expression and emotional processes of the one being confronted (“you message”), as well as on the one who is confronting (“I message”). After twenty years experience in the T.C. “The Kiem”, R. Bracke recognises the need for renewal: “It regularly happened that the radical method failed to penetrate the “imago”, and that the person hiding behind the image was left feeling broken, humiliated, and forsaken. Even if it is true that many people have been helped through this approach, one must recognise that many others, feeling shocked and emotionally damaged, terminate their stay.” (Bracke, 1996, p. 67). It is for this reason that Bracke pleads for a confrontation offering more security and support. He gives as much attention to the person confronting as to the one being confronted. He aims for the sort of balanced dialogue whereby each person is heard (Bracke, 1996, p.67–71). This important change is not restricted to the therapeutic community “De Kiem”, which is one of Belgium’s oldest therapeutic communities. It started in 1976, initially as a department of the specialized psychiatric hospital “De Pelgrim”, where young drug addicts provoked many problems as client centered therapy, medication and token economy failed. It became independent in 1978 and was developed in accordance with the principles of the T.C. hierarchic concept. The main staff were first trained as residents (R. Bracke was a member) and help was enlisted from Emiliehoeve in the Netherlands and from Last Renaissance in Washington.
From the beginning it developed it’s therapeutic approach in close collaboration with the University of Gent. In the early days confrontation groups formed the main therapeutic tool; then slowly but surely, a tradition of more dialogue and understanding developed. This coincided not only with the experience of the staff and the conclusions drawn from past mistakes, but also with a change in that direction taking place in most European therapeutic communities.
This tendency is more pronounced in Europe than in the States, where the “old” approach still persists. The influence of professionals and humanism has helped to develop this approach. It provided an answer to the reproach made by former residents, some of whom deprived of necessary attention simply because their behaviour was friendly and amenable. This discussion led to another issue: the rules of the original encounter groups were simple and their application easy, whereas the new techniques of confrontation – characterised by respect and dialogue – require training, experience and a great deal of self-knowledge.
A comparable evolution can be seen in the development of therapeutic centres for children. The basic principles are: the new school movement, psychoanalytical insights (Winnicot) and the most modern educational theories concerning dialogue. This approach is characterised by concern and connection, development of the individual within the group, freedom and responsibility.
Research
The first research into T.C.’s was largely limited to a simple gathering of data. T.C.’s based their success on the number of drug-free days. They initiated their follow-up research from the moment of graduation, which they justified by claiming that those who did not complete the programme had only themselves to blame for a presumed failure. Some early studies were better designed and followed the American empirical model. They originated with professionals within the T.C.’s.. In his book on Therapeutic Communities, M. Kooyman stated: “During the period of accumulating information, the psychiatrist, who is also the author of this research, was in addition the director of the T.C. in question. This facilitated the indispensable co-operation between teams necessary to the completion of this research, which took place over a period of several years” (Kooyman, 1993, p.199). However it seems fair to accept that European T.C. research is still new. The following researchers however: Zimmer – 1993; Norris – 1988; Berglund, Segreaus, Anders, Björling – 1991; Herbst & Al. – 1992; Hanel – 1992; Ravndal – 1994; Broekaert et. al. - 1999) were the first independent professionals who carried out follow-up studies throughout Europe, and released detailed results with regard to T.C.’s. In addition, the more complex research on dual diagnosis and relapse prevention that is being carried out in most European countries, within the framework of Biomed II of the Common Market (Kaplan, Broekaert, Dercks, Moral, 1997–1999, University Maastricht and Ghent) is almost exclusively in the hands of professionals “from outside the community”. Within those networks there is a wide scientific interest for a quantitative (EuropAsi, Maps, M.S.N.S) as well as a qualitative approach (Video Addiction Challenge Test). Close collaboration with T.C. researchers in the field is widely appreciated (G. Papanastasatos, Kethea, Greece; Chr. van der Meer, Emiliehoeve, Netherlands; V. Raes, De Sleutel, Belgium). Considering all this, it is remarkable that the old and first “European Workshop on Drug Policy Oriented Research” (E.W.O.D.O.R.) network still exists and continues to expands. These independent researchers were not always welcomed with open arms by professionals in the T.C.’s. Those whose work was characterised by their enthusiasm and by the extent of their personal input, felt ill at ease when faced with research which used surveys based on classic medical terminology.
The T.C. staff readily understood that research could penetrate the heart of daily therapeutic work. The scientifically based questionnaires and diagnostic methods were added to the written life story. It made comparison possible with the population of other T.C.’s and led to a more common language which facilitated communication with other treatment centres such as psychiatric hospitals. (Broekaert, Raes, Soyez, 1997) Adapted diagnostics went hand in hand with the differentiation of treatment for specific groups. The treatment of psychotic and borderline residents is better adapted to their needs, with less external pressure. Sexual traumas during childhood are recognised as a major problem. Dual diagnosis such as depression and addiction is accepted. Research has also revealed that the Time In Programme is one of the main – and only - predictors of success. For that reason therapeutic techniques for relapse prevention have been developed. (Broekaert, Raes, Kaplan, Coletti, 1999)
G. Deleon’s advanced work led to a questionnaire that explores the client’s circumstances, motivation, readiness and suitability for treatment (C.R.M.S.). He also developed a scale enabling us to know whether a T.C. measures up to the the expectations and criteria of adequate functioning (Therapeutic community scale of essential elements questionnaire). Qualitative (action) research stressed the importance of a regulative cycle of science in which assessment, action planning, action and evaluation regularly alternate. It strives for methodical and adequate treatment. It makes shortcomings clear, strives for improvement of treatment and questions therapeutic methodology. (Broekaert, Raes, Soyez, 1997) It was no easy transition for the staff of the community who wondered whether scientific demands should not take second place to the therapeutic importance of responsible love.
CONCLUSION
The therapeutic community for addicts had to cope with current changes. Without losing it’s basic principles it adapted to family therapeutic and network approaches. It changed its confrontational methods in favour of dialogue. It expanded its professionalism and made possible a move to a scientific approach. It is logical that in times of uncertainty people long for traditional value systems and that one has to find a balance between innovation and the security of the past. The T.C. will have to be open to gradual change without losing it’s essential nature. These solutions cannot be found in a recipe book. They are based on common effort, acceptance of differences and social learning. The secret behind the remarkable positive progress probably lies in the educational character of the T.C., which offers an opening for the integration of different models and schools of thought.
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Footnote
(1) D. Ottenberg is the former Director of Eagleville Therapeutic Community, Philadelphia