Therapeutic communities: thinking outside the box.

If it takes an entire village to raise a child, what does it take to maintain an adult, disaffected substance abuser, convicted and imprisoned for yet another felony offense? One thing most correctional administrators know for sure is that there is no one-size-fits-all method of managing the lives of men and women in a correctional environment. Faced with ever-decreasing budgets and staff recruitment woes, administrators also are dealing with managing an increasing number of these sometimes dually diagnosed offenders.

The provision of health care in the correctional environment has been a major challenge throughout the past two decades. That challenge has been particularly robust as it concerns the delivery of mental health services, and it has not been helped by the fact that the criminal justice system has replaced community service providers. At the same time, nothing has been more pervasive in society than drug use and the drug culture. The impact of drug-related crime is reflected in the disproportionate number of individuals committed to correctional facilities for drug-related offenses. The treatment of addictive behaviors has been an exceptionally worrisome issue for society, in general, and corrections, in particular. This group of offenders is unusually problematic as a result of their tendency to re-offend and return to the criminal justice system. It is likely that this in-and-out process, and the crowding generated by it, has been the genesis for efforts to address the treatment of this offender group.

Throughout the years, many treatment models that address the substance abuser have been tried. Most have had some measure of success; however, they have been inconsistent in application and result. Although the therapeutic community approach has gained favor in recent years, the term therapeutic community has not always been clearly defined, It has been described as a community of addicted individuals who live together in a structured environment that includes a code of behavior, peer-to-peer confrontation and discipline, and professional counseling. Or, as articulated by the Association of Therapeutic Communities, a therapeutic community is "a highly structured pro-social environment for the treatment of drug abuse and addiction."

Simply stated, a therapeutic community is a program that relies on interactions within the peer group to help members confront the reality of their addictions and to subsequently commit to a lifestyle change that will enable them to remain drug- and crime-free. However defined, the therapeutic community offers a clear structure of boundaries and expectations. The therapeutic community for drug abuse treatment is a concept that has existed for about 40 years; however, there are many new approaches. Although common in the free community, its application in the prison environment represents a relatively new use. To that end, a number of studies have documented the success of the therapeutic community model of treatment. One such study states that 80 percent of the therapeutic community graduates will remain drug-free for three to five years, according to the book Treating Drug Problems. Also, in Brian Shapiro's article, "The Therapeutic Community Movement in Corrections," which appeared in the February 2001 issu e of Corrections Today, he states that "without treatment of any type, it is estimated that 70 percent of all inmates released in this country eventually will be reincarcerated."

Recidivism rates have been found to drop considerably after treatment in a therapeutic community, according to Treating Drug Problems. Yet, what has been learned from the use of this treatment model has not, until now, been codified and replicated -- in other words, standardized.

The fact that the therapeutic community is expected to exist within an institutional framework makes it all the more interesting. Therapeutic communities, by their very nature, exemplify the process of thinking outside the box. In the case of corrections, as mentioned, they represent a community within a community that is truly unique. This is important to note since often, the rules and mores of the larger institutional community are in conflict with the smaller and more concentrated therapeutic community. In the previously mentioned Corrections Today article, Shapiro, who is the program manager for FRIENDS (Finding Recovery in Each New Day's Sunrise) at the Idaho Correctional Institution, provides a history of the therapeutic community in prisons and chronicles the workings of several of these programs within the Texas Department of Criminal Justice. It is an excellent orientation for those unfamiliar with this treatment methodology. Shapiro witnessed firsthand how those programs function, inclusive of Ther apeutic Peer Reprimand, which, according to the Shapiro article, is a final attempt by inmates and staff to bring negative and destructive behaviors to an individual's attention, and confrontation groups.

Although a therapeutic community is essentially a mental health program, buy-in and support by facility administrators is pivotal to its success. In fact, without that unqualified support, it is unlikely to succeed. As David Kennard stated in a paper at the Psychological Solutions to Personality Disorders Conference, March 14-15, 2000, "Therapeutic communities generate anxieties, especially in managers whose job it is -- as they see it -- to control others and to present a tidy, well-managed, crisis-free picture to the world."

The emergence of the therapeutic community in corrections represents a useful approach to treatment. In order to help correctional facilities obtain and maintain a viable treatment product, the American Correctional Association's (ACA) Commission on Accreditation accepted the responsibility to develop measurable standards for therapeutic communities, and ACA's Standards and Accreditation Department has spent the past several months developing Performance-Based Standards for Therapeutic Communities. The final draft of the standards for institutionally based programs is complete and was approved for field-testing by ACA's Standards Committee in January. As performance-based standards, they include expected practices, protocols, process indicators and outcome measures. The outcome measures assist in the development of a data collection system that measures events, occurrences, conditions and behaviors.

Typically, field-testing is conducted by volunteer facilities or programs, which agree to put the standards in place, collect data on their use and impact for 90 days and, for a significantly reduced audit fee, undergo an audit and subsequent accreditation. The use of these standards and the accreditation process is very much dependent on a broad cross-section of input from the field. Volunteer program participants are needed and institutional programs are encouraged to become part of the testing process.

Cecil Patmon is a regional manager in the American Correctional Association's Standards and Accreditation Department. To participate in testing the new standards, contact Patmon at [phone]; e-mail: [e-mail]