The Therapeutic Community for Drug Abuse Treatment: A Journey Yet Unfolding in the Recovery Movement

Introduction

Since we finished this chapter in 2012, there has been a notable gap in therapeutic community outcome research. Although systematic reviews of the research in recent years on the therapeutic community conclude that therapeutic communities produce positive outcomes on substance use, employment, criminality and psychological health, both interest and financial resources in support of this model have atrophied. Chief among the likely causes of this wane in interest in the therapeutic community model are funding sources that are increasingly limiting treatment duration and intensity, and the overarching concerns with promoting treatments whose effectiveness can be demonstrated in randomized controlled trials (RCTs). The random assignment of clients to treatment is ethically and practically challenging, as is the reduction of a purposefully multifaceted intervention such as the therapeutic community to a single controlled independent variable.

What studies that are marginally present seem to end by 2012 and those were of the therapeutic community in correctional settings. Even in this limited scope (i.e., prison-based treatment of substance use disorders) the therapeutic community model has given way to the pervasive dominance of evidence-based treatment practices, particularly cognitive behavioral therapy (CBT). Although many studies have supported the CBT outcomes, particularly in the management of depression and anxiety, which have had years of positive outcomes, these approaches have shown declines in effectiveness in the past few years. The looming suspicions for this reversal are the fidelity of implementation, a problem associated with all of the RCT-supported treatment practices, most of which demonstrate their outcomes under conditions that are difficult to replicate with the resource limitations with which most substance use disorder treatment programs operate.

As with the limits imposed on substance use disorder treatment in the greater community, the longer-term therapeutic community approaches in corrections have been curtailed by housing and population control measures aimed at moving inmates out as soon as they are perceived to be safe to the greater civilian community.

Is this the beginning of the end for the therapeutic community model, once heralded as a breakthrough treatment, showing ambitious and meaningful outcomes on abstinence, employment, criminality, and psychological improvement?

Origins

It is wrong to assume that there has always been a specific and widely accepted understanding of what is meant by a therapeutic community. The designation has an ancient pedigree and a historic association with diseases of appetite and the concept of mutual help. By the late 20th century, it had come to identify a specific mode of treatment for substance misuse, addiction, and other behavioral disorders based on the power of the treatment community to change attitudes and behavior through mutual help and a regimen of structured activities and expectations. This is a regimen designed to promote compassion and responsibility, foster self-awareness, enable social learning, and make possible the acquisition of social capital.

At the dawn of the Christian era, in 25 BCE, Philo Judaeus wrote,

They are called communitae therapeutrides … because they profess an art … more excellent than in general use … for medicine only heals the bodies but [these] heal the souls which are under the mastery of terrible … incurable diseases of pleasures and appetites.”

(Curiously, the term “appetitive” became a neurobehavioral declaration regarding addictive behavior in the late 20th and early 21st centuries—as supported by neuroimaging techniques that became available in the late 20th century.) Thus it appears that the struggle with uncontrolled appetite behavior was a challenge then, as it is now, and the ancients embraced an approach not unlike the therapeutic communities of today.

We can presume that Philo, writing in Alexandria early in the 1st century, was describing the early Essene communities, where according to the Qumran Community rules of order and duty, life was meant to conform to the following principles: concern for the state of our soul and our physical survival; search for meaning (transcending truths); challenge and admonish with love; be invasive—accountable to the community; public disclosure of acts, fears, hopes, guilt; public expiation for wrongs done; banishment is possible—done with concern for survival; and leadership by elders—by models.

These same principles have been present in mutual help communities from early monastic splinter groups to the much later Methodist congregations that espoused a “return to first principles” and morphed into the early Oxford movement. It may well be that combining two sets of rules—one imposing rigid moral and behavioral standards and the other promoting humanizing compassion and forgiveness—is why these principles have so often and so successfully been brought to bear on delinquent or deviant behavior, problems of social maladaptation, and finally on addictive behavior and other problems of appetite.

This can be seen in the spread of religiously based mutual help societies in Western Europe during the 17th and 18th centuries. Responding to the widespread overuse of alcohol, they launched temperance efforts in Europe, which spread to America. Many of these early attempts at appetite control included temporary residential support and pledges of abstinence. Key principles embraced by these mutual help groups included disclosure (confession), admonition, commitment, and conversion of others. By the 1800s, the spread of these principles had influenced the development of the Washingtonian and numerous other small groups.

Before World War II, however, the term “therapeutic community” occurs only once, when it was applied to the care of orphans in 18th century Russia. It was next revived in wartime England at Northfield Hospital, a facility dedicated to the treatment of traumatized British troops. There, two psychiatric innovators, Maxwell Jones and Tom Maine, sought to reapportion authority and decision-making between staff and patients. ^.

They began referring to the democratic therapy that they introduced at Northfield Hospital as a therapeutic community, designed to reverse the dynamics of the traditional psychiatric hospital, which many had come to believe infantilized patients, exacerbating their disability and rendering them incapable of functioning outside the hospital environment. Patients in Northfield psychiatric units became the active decision makers, taking on increasing responsibility for ward management. Early discussions among these pioneers resulted in five basic assumptions: two-way communication at all levels; decision-making at all levels; shared leadership; consensus in decision-making, and social learning by social interaction with emphasis on the here and now.

The horizontal, open system of communication, based on those five principles, was itself assumed to result in healing. It did, in fact, produce marked improvement among community members, and such success made the need for individualized treatment plans seem unnecessary (a notion that would later become doctrine in American drug treatment therapeutic communities). Maxwell Jones went on to become a teacher of this method in Europe and the United States throughout the 1950s and 1960s, influencing younger psychiatrists, particularly at state psychiatric hospitals in Washington, Oregon, New Mexico, and other Southwestern states. However, not until the late 1970s did Jones become aware of and engage with the American drug treatment therapeutic community movement.

The drug treatment therapeutic community was not introduced by any of the nurses or psychiatrists who, inspired by Jones, sought to develop similar treatment models. Its origin is attributed to a group that emerged in Venice Beach, California, in 1958, when an Alcoholics Anonymous member, Charles E. (Chuck) Dederich, started an organization he called Synanon, embodying mutual help principles of Alcoholics Anonymous and characterized by hierarchical structure, a semi-open communication system, and small group interactions focusing on behavioral change.

Not unlike other charismatic and gifted figures, Dederich brought his own background—corporate, Midwestern, and Depression-influenced—to the organization he founded. As is often the case when strong leading theoreticians mount efforts designed to alter human behavior, the organization took on the personality of its founder. Imitation of the leader—in dress, language, and general demeanor—became a defining characteristic of Synanon and an influence on subsequent therapeutic communities.

Dederich launched Synanon by breaking away from the Alcoholics Anonymous group he had been attending. Within the tradition of Alcoholics Anonymous, anyone can pick up the Big Book and start his own meeting. When Dederich and the few members who followed him started their meeting in Venice Beach in 1958, the community was loaded with “alkies,” “pill-heads,” and a few “junkies.” These people, living on the edge of society in the pleasant, hospitable, Southern California beach community, were sleeping on the beach, begging for money, making drug deals, and essentially staying intoxicated with the drug of their choice or whatever else they could get. It was a setting ripe for an evangelical salvation-oriented mission.

With the help of a dedicated few, Dederich and his followers obtained funds to open a club and, in a tradition easily traced back 200 years, encouraged folks to drop in for conversation in hopes of gaining sobriety. Dederich began holding long meetings in which his innate verbal talents and wide range of interests—from corporate structures to Zen and Transcendental philosophies—drew growing audiences and proved a powerful magnet for membership.

Hearing of these meetings, the availability of food and rumors of easy sex, a few heroin users recently released from the California prison system dropped in. Contrary to their expectations, they were immediately confronted by a loud, bombastic host, who assured them they were welcome, but only if they were willing to help out. “There’s no free lunch,” Dederich told them, and this proved an attractive challenge to some, since it was such a departure from the traditional social work style they anticipated.

A nascent community came into being made up of Dederich’s Alcoholics Anonymous cadre, former prisoners, quasi-homeless addicts from the beach, and an upscale contingent of musicians and other artists. Core members from outside the area began moving in, renting the readily available small cabin rooms along Venice Beach. Later in that first year, the group acquired an armory on the beach in Santa Monica, which gave members a chance to live together, pool their funds, share meals, and begin to seek financial support in the community, soliciting donations of cash, foodstuffs, and other living supplies. It also challenged Dederich to organize, preside over, and control community life.

A large man, highly verbose and partially deaf, Dederich spoke at length and high volume. He loved to argue and debate, inspiring heated confrontation among members. These confrontations became a common style of interaction within the group, valued for the relief that many members claimed such abrasive exchanges brought them. Soon formalized, this mechanism was first called “The Synanon” after the name of their organization. By 1964 the Synanon began to be referred to as the “game.”

It is from the Synanon game that the therapeutic community encounter evolved. What Dederich added to the fundamental Alcoholics Anonymous mechanism of self-disclosure was the muscle of confrontation. Alcoholics Anonymous rejects both invasiveness and cross-talking. Although no one at an Alcoholics Anonymous meeting interrupts, questions, or challenges a speaker, the game encouraged this kind of spirited exchange.

As the game developed, so did the ethical demands of mutual responsibility. Although no drug use was an early requirement of the group, many members continued to use. Troubling questions arose: What then is the responsibility of others in the group? Are they obliged to expose their drug-using fellow members?

The issue came to a head at what later became known as the “Night of the Big Cop-Out,” when a number of drug users were “outed” and others “copped to” their use. At this point, the role of the community as monitor was established along with the principle of expulsion from the group for drug use.

As a daily schedule took shape, work tasks necessary to operation of the community were assigned and a schedule of daily seminars established to broaden the intellectual horizon and knowledge base of members. A distinct corporate-like hierarchy was formed, with a top-down structure based on coercion (“our way or the highway”) and leadership determined and rewarded by Dederich. The early rewards included special living quarters, special food, access to vehicles, and the ability to acquire girlfriends or boyfriends and sleep with them. (The euphemisms were “courting” and “steady dating.”)

Early on, Synanon began organizing the process of drug treatment into a series of phases. Phase One was live in and work in; Phase Two, work out and live in; and Phase Three, live out, work out, and maintain membership. But very soon, by 1960, Phase One had grown from 2 to 6 months in response to relapse among members in Phases Two and Three. By 1962, during a period of rapid membership growth, Phase One was extended to at least 1 year. Nevertheless, relapse continued to occur in Phases Two and Three. As a result, the work out and live out phases were entirely eliminated in 1964, with Dederich rationalizing that “Our members remain healthy and drug free while with us—so that we are obviously a healthier community than is the greater society.” At this point, the effort once labeled by Life magazine as a “Miracle on the Beach” began its drift into increasingly wilder utopian community fantasies and ultimately into a cult capable of criminal behavior (pleading no contest to charges of soliciting an assault and conspiracy to murder).

Early Expansion

Not surprisingly, and consistent with the experience of other psychosocial movements, there were breakaways from Synanon by 1964. These breakaways, while troubled by the Synanon’s flaws, still took with them a deep belief in the essential elements of a treatment model that had made it possible for them to achieve and sustain abstinence. They also, however, carried with them a vision of treatment as redemption and the Synanon belief that they had the only right answer. Theirs was a point of view that perceived addiction, if not as a moral weakness and sin, then as a disorder of character. Thus they were not only entitled to, but charged with, correcting such flaws by whatever means necessary within the limits of the law.

It was at this moment that new opportunities were created by growing demand for a response to the seemingly intractable problem of addiction to heroin and other illicit drugs. By the early 1960s, heroin use was expanding, particularly in urban America. The accompanying increase in crime brought to the surface public frustration with the failure of stern anti-addiction measures to effect change. Longer and longer minimum mandatory sentences for drug law offenses and civil commitment of addicts for treatment with lengthy stays in federal hospitals did not produce abstinence outcomes.

The notion that abstinence might not be a rational expectation had surfaced back in the early 1950s when Victor Vogel, MD, who then oversaw addiction treatment at the United States Public Health Hospital at Lexington, Kentucky, wrote that “If treatment results are compared with those in other chronic or recurrent diseases such as TB… arthritis… hypertension … diabetes … or cancer—results in this field (drug treatment) are good.” But this early glimpse of addiction as a chronic disease was ignored. Both the public and the afflicted either hoped for or wanted an answer called “cure.” Synanon had promised such a miracle and so did the first spin-off, Daytop Lodge in New York.

Daytop Lodge was a research project based on Synanon. It was supervised by Brooklyn’s Chief of Probation Joseph Shelly and his lead psychologist Alex Bassin. The acronym stood for Drug Addicts Treated on Probation. The population consisted of 35 male felons who accepted treatment at Daytop under probation supervision rather than prison sentences. This marked a serious departure from the mutual help members involved in volitional recovery. Money in the past was begged or provided as charity. Now it was underwritten by government and administered by a criminal justice agency. It should be noted that this was the first step in what came to be known as therapeutic community institutionalization, and a new term, “ex-addict,” came into use. The project had a shaky start with a rapid turnover of leadership. In October 1964, under a new and more experienced leadership team and with increased financial support from New York City, the program was reorganized, and Daytop Lodge morphed into Daytop Village.

Probation was no longer a requirement for admission, and the program now accepted women. A board of directors was formed, chaired by co-founder Monsignor William B. O’Brien, a Bronx priest with strong ties to the New York archdiocese. Alex Bassin joined the board. Daniel Casriel, M.D., a psychiatrist who had written the first book about Synanon, So Fair a House , was now psychiatric director and David Deitch was clinical and program leader. Soon, a growing number of candidates sought admission, and by the end of 1965, there were 100 members/residents in a larger facility.

In 1966, New York City’s mayor, John V. Lindsay, recruited Efren Ramirez, MD, a psychiatrist from San Juan, Puerto Rico, to coordinate the city’s narcotic treatment programs as commissioner of the city’s new Addiction Services Agency. Dr. Ramirez had already developed systems of community engagement, protracted client induction processes, and treatment approaches similar to those of Daytop Village (“Daytop”). Ramirez developed a close working relationship with the program, and Daytop staff became a resource for him as he set out to expand the city’s response to a growing heroin epidemic. It was Ramirez, trained in the Max Jones model, who persuaded Daytop, which had been calling itself a “humanizing community,” to adopt the term “therapeutic community” to better describe its approach.

Dr. Ramirez was soon joined by Mitchell S. Rosenthal, MD, a psychiatrist who had developed an alcohol and drug treatment hospital unit at the Oak Knoll Naval Hospital in Oakland, California. There, he had introduced many of structural and group characteristics he had observed at a Synanon facility in San Francisco. Ultimately, Ramirez made him deputy commissioner for rehabilitation.

Commissioner Ramirez was also reaching out to other young psychiatrists in hopes of expanding addiction treatment. He created a weekly get-together of Deitch, Rosenthal, and a young psychiatrist still in residency training, Judy Densen-Gerber Baden. These meetings provided the impetus for an explosive growth of the model in New York City. Rosenthal developed Phoenix House, and Judy Densen-Gerber created Odyssey House. Daytop lent staff to each of these projects, and help also came from other former Synanon members.

In short order, these projects spun off other new starts: Samaritan Village and Project Return in New York City; Gaudenzia in Philadelphia; Village South in Miami; and Gateway in Chicago. All of them shared many similar beliefs, hierarchical structures, group activities, and goals.

There was also a significant role in the expansion of the therapeutic community played by the young psychiatrists who finished their training and served in the US Public Health Service. The earliest concentrations of addiction treatment were located at the US Narcotic Farm in Lexington, Kentucky, run jointly by the Public Health Service and the US Prison Service, and a similar facility in Fort Worth, Texas. These facilities accepted voluntary admissions as well as addicts convicted in federal territories or found guilty of federal offenses.

Three of these psychiatrists emerged as leaders in addiction research and treatment. Jerry Jaffe, who was to become the first White House director of the Special Action Office for Drug Abuse Prevention, currently referred to as the Office of National Drug Control Policy, became familiar with therapeutic community methods at Daytop while at Albert Einstein Hospital in at New York City. Recruited by the Department of Psychiatry at the University of Chicago to serve as the director of drug abuse treatment programs for the State of Illinois, he subsequently recruited two Daytop staff members who helped him to further develop Illinois’ first therapeutic community, Gateway Foundation. In order to secure a facility for Gateway, Jaffe took a lien against his own home so that the therapeutic community model would be part of the broad array of programs, from outpatient detoxification through methadone maintenance, he created in Chicago.

A second US Public Health Service psychiatrist, Herbert D. Kleber, had his introduction to addictions at the Lexington Hospital and went on to the Department of Psychiatry at Yale’s medical school. There, he recruited Daytop staff to develop a separate Daytop Connecticut in New Haven. Kleber was subsequently tapped to become the Office of National Drug Control Policy’s first deputy director for demand reduction. Another US Public Health Service Hospital psychiatrist, Fred Glaser, helped bring the therapeutic community program Gaudenzia to Philadelphia while teaching at Temple University.

This rapid spread of therapeutic communities was made possible by program members seeking a cure and communities in search of new and better ways to confront addiction. Unlike the Alcoholics Anonymous movement, which holds that “members are in recovery not recovered,” the therapeutic communities believed that cure was possible. This belief was reinforced when peers were seen to succeed. Use of the term “ex-addict” grew, and the expansion of the therapeutic community was now fueled not only by former Synanon members, but by graduates of these new and exciting programs.

Proliferation of the therapeutic community was carried on a wave of optimism characteristic of the era—a period of seemingly infinite possibilities, before the war in Vietnam clouded the political landscape. The climate of the times made possible the spread of therapeutic community doctrine by outsiders, for here was a treatment model with no academic provenance or research history that essentially invented itself. Pioneering psychiatrists who embraced the model did not come from the medical or mental health mainstream, and few of those first-generation program leaders had any professional credentials at all. What they did have was an ideology. The concept of giving to get—the notion of helping others to facilitate one’s own recovery—was a philosophical cornerstone, as was the belief that healing was possible only when one was part of something greater and more important than oneself. The men and women who staffed the early therapeutic communities strived to submerge their separate identities. To them, the golden word was “we.” Many of these early staffers—formerly gone astray, isolated and addicted themselves—needed that merged identity to heal themselves before they could help others heal.

As Deitch wrote many years later,

These outsiders … created humanizing communities that espoused dignity of all people, equality between races and sexes, nonviolence and peace, heightened consciousness and spirituality, and action as the road to personal and social change. These first-generation ideologists committed themselves to a way of life that provided health, safety, caring, and honesty—sometimes brutal honesty. They censured deception, cheating, and gain at others’ expense. The original version of these early crusaders—a vision that still holds true today—was a commitment to live and act as agents of positive social transformation. We believed that what goes around comes around.

The Formative Years