Therapeutic communities: history, effectiveness and prospects.
Seven out of every 10 men and eight out of every 10 women in the criminal justice system are drug users - persons who used illicit drugs with some regularity prior to entering the criminal justice system. The Federal Drug Use Forecasting system data show that the use of all drugs except cocaine has increased since 1989, and cocaine remains at the same level. Accordingly, the 1990s have seen major increases in arrests of drug users, followed by pressure for funds to expand correctional capacity to treat those inmates with serious drug problems. Interestingly, with this increase has come increased public support for programs aimed at treating drug users and curbing drug-related crime. There is a genuine public and government concern that without treatment, most drug-involved offenders will resume their criminal activities and drug use after release and inevitably will return to criminal justice system custody.
The 1994 Crime Bill included, for the first time, a substantial sum provided for treatment of inmates in state and local correctional systems. The Residential Substance Abuse Treatment for State Prisoners Formula Grant Program (abbreviated RSAT) legislation created an opportunity for states to apply for funds to establish residential substance abuse programs beginning in 1996. In conjunction with this legislation, Congress has authorized spending $270 million for the first five years of the program, the largest sum ever for the development and enhancement of substance abuse treatment programs in state and local correctional facilities.
Largely because of research showing that prison-based therapeutic community programs can significantly reduce recidivism and drug relapse, RSAT legislation encourages the development of this residential treatment model, in addition to other viable treatment approaches, including cognitive skills training, behavioral programming, vocational methods and even 12-step programming.
Historically, the term "therapeutic community" (TC) has been used for several different forms of treatment - sanctuaries, residential group homes and even special schools - and for several different conditions, including mental illness, drug abuse and alcoholism. For example, the British TC emerged primarily as a process for treating military veterans as they returned from WWII with serious neurotic conditions from their experiences in combat and as prisoners of war. The term was coined when Thomas Main pioneered a therapeutic model combining community therapy with ongoing psychoanalytic psychotherapy in 1946. This was a modification of therapeutic work developed about the same time by Maxwell Jones and several others. By 1954, TC ideas were influencing wards in British psychiatric hospitals.
At about the same time, the use of tranquilizers began to emerge as the dominant "treatment" for institutionalized, mentally disordered persons. Drastic reductions in psychiatric beds and other confinement beds occurred as facilities closed down. In the 1950s and 1960s, the TC movement shifted toward other milieus, notably corrections, and TC principles began to guide offender programs in the United Kingdom. Grendon Prison was built in 1959 specifically with a number of wings within which TCs would experimentally operate to provide treatment for psychologically disturbed offenders.
The British prison TCs operate within these principles:
* enfranchisement and empowerment, "wherein every community member has a direct say in every aspect of how the wing is run" (including the power to vote someone out for a rule breach);
* a philosophy of tolerance to allow members to make mistakes, and to accept themselves "with all their warts" and support each other "regardless of their warts";
* encouragement of individual and especially collective responsibility and accountability;
* continuous, direct and candid presentation of interpretations of one another's behavior to counteract any tendency to distort, deny or withdraw from interpersonal difficulties or rule breaking; and
* peer group influence, used to control and modify inimical prison cultural values with an important role for "community elders" - members who have successfully completed the transition themselves and who now play a supportive role.
Therapeutic goals include: getting past denial; relief of intrapsychic distress; developing relationships with women and children, authority figures and one another; changing attitudes toward offending, and specifically to one's primary offense; building morality, victim awareness, contrition and understanding of effects on victims; and relapse prevention. At HMP Grendon, the treatment program lasts for more than two years, and consists of daily small therapy groups of 10 residents run by two staff members (one psychologist and one trained officer); daily community "wing" meetings of 35 to 42 (and as many as 50); "feedbacks" or confrontation sessions; and cognitive skills, psychodrama, social and life skills, alternatives to violence and educational programming.
In the United States
American TCs have a different origin. They tend to be for drug-dependent and drug-abusing persons and derive from Synanon, which was both a social movement and a program founded in 1958 by Charles Dederich, a recovered alcoholic who, unfulfilled by Alcoholics Anonymous, founded his own racially integrated community of former addicts and ex-offenders. Synanon consisted, in part, of a kind of group therapy with intense emotional catharsis-type participation sessions; fairly "brutal" confrontation sessions; educational seminars; and discussions, not of drugs, but of self-image, work habits and self-reliance. Synanon, which got its name when a newly arrived addict confused the terms "seminar" and "symposium," bears many similarities to today's Phoenix House and Daytop Village programs, although these programs tend to be considerably less intense.
The U.S. TC model is less psychoanalytical and psychotherapeutic than the U.K. model; it is less focused on the criminal offense or on substance abuse per se and is more holistic, i.e., more concerned with lifestyle changes across more dimensions. The U.S. model uses the "community of peers" and role models as change agents rather than professional clinicians and trained correctional officers, and it is less democratic in operation and more hierarchical in structure. The U.S. model also is less psychiatric (and less medical) in origin, emerging from a recovered client self-help background. Thus, American TCs (also called concept-based TCs) generally subscribe to a self-help, social learning model approach and a holistic human change perspective.
In 1969, the first correctional TC that served as a model program began in the federal penitentiary in Marion, Ill. The prison psychiatrist, Dr. Martin Groder, designed and developed a TC based on his transactional analysis training and group therapy experience in California. The program combining these two general approaches was named "Aesklepieian" for the Greek god of healing, and consisted of intensive group counseling using the "community" or peer group as the vehicle for change, combined with the concepts and language of transactional analysis. While it did not meet the criteria we now have for this kind of treatment, it still served as a model for the development of correctional-based TCs in federal and several state institutions in the early and mid-1970s.
With the availability of Federal Law Enforcement Assistance Administration funds in the 1970s, even more prison TC programs were developed. For example, between 1975 and 1977, four institutions in Arkansas developed prison-based TCs, including one for female offenders; all were discontinued in 1980. Eight TCs began in Connecticut about the same time for persons addicted to drugs. Connecticut also established a TC for women at Niantic and one for juveniles at Cheshire, as well as several community-based correctional TCs. None of these programs followed the Aesklepieian model, but adapted the Daytop treatment model, which was much closer to the current prison-based TC model than Aesklepieian.
A TC was established in the Atlanta Penitentiary in Georgia in 1982, but was closed down in 1985 because of staff burnout and a lack of fresh volunteers. A TC for women was established in Michigan in 1977, moved to a smaller facility in 1982 and closed down in 1984, but reopened in 1988 and continues today. Missouri launched a TC for sex offenders in 1981. Close examination reveals that while separated from other inmates, members never established a community structure and were dispersed to the general population in 1988.
For five years, from 1979 to 1984, Nebraska ran a TC at Lincoln, but it closed after encountering a variety of problems, including friction between program staff and institutional staff, a negative investigative article by a reporter, crowding and declining state revenues. In 1979, Florida developed the Lantana TC for youthful offenders, which was cited as an exemplary program by the federal government. It lasted until 1987, by which time it had lost energy and focus.
Using the community-based drug abuse treatment program Phoenix House as a model, the Stay'n Out program began in 1977 in New York. It is still operating quite successfully as a treatment program, and now has five units treating 180 men at Arthur Kill Correctional Facility, and about 40 women at Bayview Correctional Facility. The staffing is contracted and still consists mainly of recovered, formerly addicted, ex-offenders. The cost per year, per inmate participant is less than $3,000. Stay'n Out has lasted longer than most correctional programs, in part, because it has developed strong ties to the political and academic communities; educated and cultivated both substance abuse and correctional administration officials as well as line officers; encouraged careful and thoughtful long-term evaluation; and informed the public of its activities and accomplishments through the media.
Oklahoma began six small TCs in 1973, one of which was for drug offenders. All six were closed in 1979 when their primary proponent retired. The institution in which they were housed was torn down, and replaced with a new reception center. Oregon's Cornerstone program, a 32-bed therapeutic community for inmates that began in 1975, closed in 1996. A concept-based TC like Stay'n Out, Cornerstone differed by employing a higher proportion of professional staff and trained correctional officers than Stay'n Out. Thus, the cost of treatment at Cornerstone was greater than at Stay'n Out. Cornerstone's cost per day, per participant at the time of its closing had reached $39, making its cost comparable to that of some community-based TCs.
A TC was started in 1975 in South Carolina; it lasted until 1979, by which time it had become crowded, corrupted with contraband drugs, and inadequately staffed. In Virginia, a TC called House of Thought was established on the Aesklepieian model. After overcoming strong institutional resistance and unfounded rumors of misconduct, the program grew, moved to Powhatan Correctional Center in 1980 and lasted until late 1982, when it was closed after a decline in state revenues forced budget cuts and its director resigned.
Thus, a number of prison-based TCs developed in the 1970s and through the early 1980s. A variety of models existed - Daytop, Aesklepieian, Phoenix House - but not all of the programs focused on drug abusers; some were designed for sex offenders, some for disturbed inmates, and some for offenders with no particular disorder other than a history of criminal offending. The life span of the programs averaged five to seven years. Most closed when executive priorities changed and/or revenue shortfalls reduced funding availability. A few became corrupted when supervision weakened and contraband drugs were brought in. Some were never able to develop a true community. Others, like the 20-year-old Stay'n Out program, remain viable today. In many cases, however, closed TCs were replaced by new TCs. It is important to note that the theoretical underpinnings and operating standards of TC practice for most of these early programs, except for the Stay'n Out program and Cornerstone, would have met few of today's TC standards.
The New Wave of TCs
The next new surge of prison-based TC drug abuse treatment programs - funded through the Federal AntiDrug Abuse Act of 1986 - were two major national technical assistance projects. These monies were, in part, granted on the success of the Stay'n Out program. During Projects REFORM (BJA-funded, 1984-87) and RECOVERY (CSAT-funded, 1988-91), the author and his colleague, Dr. Harry Wexler, along with a team of consultants, provided technical assistance to 22 states to initiate or expand comprehensive, statewide correctional drug treatment. Interesting was the catalytic effect that these efforts had on the correctional community in general. As the REFORM project grew, other states, and even other nations, began seeking materials to guide the initiation of drug abuse treatment programming for their correctional inmates. New service delivery models were created that enhanced the continuity of treatment so that programming begun in the institution could continue after program participants were released. The Federal Bureau of Prisons' (BOP) expansion of treatment is also an indirect beneficiary of these programs. In just 10 years, the BOP has gone from treating fewer than 4,200 inmates to the operation of 34 TCs, treating 30 percent of federal inmates with moderate to severe drug problems; those with less severe problems also receive services.
Project REFORM resulted in expanding, improving and/or implementing 72 assessment and referral programs; 118 drug education programs; 71 drug resource centers; 82 in-prison, 12-step programs; 15 urine monitoring programs; 128 pre-release counseling and referral programs; 49 post-release treatment programs with parole or work release; and 77 modified TC treatment programs.
In 1991, when funding for Project REFORM ended, a new national effort, Project RECOVERY, was funded by the Alcohol, Drug Abuse and Mental Health Administration to provide technical assistance and training services to demonstration prison drug treatment programs and to continue the work begun by REFORM. Nine states participated along with the original group from REFORM, and the work continued for 18 months. One net effect of these two projects was that by 1997, 110 TCs, as well as a variety of other programs, were operational in state and federal correctional institutions.
We have earlier noted the $270 million authorized over a five-year period beginning in 1996 for the RSAT block grant program, which provides funding for the development of substance abuse treatment programs in state and local correctional facilities. Like REFORM, the RSAT program encourages states to adopt comprehensive approaches to substance abuse treatment for offenders, including relapse prevention and aftercare services. In the less than two years since implementation of the act, already 70 programs have been started or enhanced in more than 40 states. While not requiring that TC programs be established with these funds, the model treatment program criteria that are stipulated are based on the powerful findings of the TC evaluation studies produced since the latter half of the 1980s.
Programs such as Stay'n Out cost about $3,000 per year, per inmate. The savings produced in reduced crime and drug use-associated costs alone, however, repay the cost of the treatment in two to three years. Moreover, the higher the investment in rehabilitating the most severe offender-addicts, the greater the probable impact. Substantial reductions in high-volume criminality have an immediate impact on the quality of life. Thus, with appropriate intervention applied for a sufficient duration, more than three out of four offenders are highly likely to re-enter the community and lead socially acceptable lives. A great many of the successful graduates of these programs in the United States had long histories of serious property crime and violent crime; this finding has important implications for the use of this modality for other offenders.
The current research shows that TCs are effective with diverse locales and populations, and that even high-rate offenders can be helped dramatically. It is clear that the greater the investment in rehabilitating the most severe offender-addicts, the greater the probable impact. However, despite these positive signs, TCs are still limited in the numbers of offenders who can be given this opportunity, and by the number of trained persons available to deliver the treatment.
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Douglas S. Lipton, Ph.D., is a senior research fellow at the National Development and Research Institutes Inc. in New York.