Unveiling the Four Views of Therapeutic Community: A Comprehensive Approach to Recovery

George de Leon played a crucial role in developing Therapeutic Community’s theory, model, and method. In his TC theory, “community as method” shapes its program model and its unique approach. This article delves into the four interconnected views that form the bedrock of this paradigm: the view of the disorder, the view of the person, the view of the right way of living, and community as a method. These perspectives collectively redefine how we understand and approach recovery.

1. View of the Disorder

The first perspective focuses on understanding the nature of the addiction disorder itself. Traditional approaches often view addiction as a purely medical or psychological condition. However, the Therapeutic Community (TC) model recognizes it as a disorder of the whole person, affecting their psychological, social, and moral dimensions. It is evident that those struggling with addiction have problems not only with cognition and behaviour, but also mood disturbances . Their individual thoughts may be classed as unrealistic or even disorganized and their values can be mixed up. Spiritual struggles, or even moral problems, are consistently apparent whether expressed in psychological or existential terms. Thus, it can be argued that the problem goes well beyond the addictive behaviour and addiction can be seen as a symptom rather than the essence of their disorder. This perspective is one of the main characteristics of the TC and one of the major differences between the TC model and standard psychiatric inpatient treatment, which is much more based on symptom-oriented diagnostic systems such as the International Classification of Diseases in 11th revision (ICD 11) or the Diagnostic and Statistical Manual of Psychiatric Disorders Version 5 (DSM 5). This holistic view implies that treatment must address more than just the symptoms; it must facilitate a comprehensive transformation in the individual's behavior, attitudes, and values.

Moreover, in terms of an attachment based therapeutic approach, it can be said that the TC tries to break the bond to a certain addictive behaviour and instead direct people toward forming a bond to the community. Thereby, the TC can serve as an attachment figure, acting as a safe haven in which one can enter, but also as a secure base from which one can start again into a new addiction-free life. While clinical evidence suggests the important role of the community for the functioning of affect regulation, some additional support comes from a neuro-evolutionary perspective e.g., through the “social baseline” model, which proposes that social species are hard-wired to assume relatively close proximity to conspecifics, because they have adopted social proximity and interaction as a strategy for reducing energy expenditure relative to energy consumption.

2. View of the Person

Central to the TC model is the view of the person struggling with the disorder. Unlike models that may portray individuals as passive recipients of treatment, the TC approach sees them as active participants in their recovery journey. This perspective emphasizes the potential within each individual to change, grow, and recover. It challenges the notion of the "addict" identity, encouraging members to redefine themselves beyond their disorder. This empowers individuals, fostering a sense of agency and responsibility towards their recovery.

Another term for the TC experience could be “habilitation” - the development of asocial, productive, and “conventional” lifestyle for the first time. Despite any differences in social background, psychological struggles, or addiction preferences most individuals admitted to TCs share profound clinical characteristics that cluster around  a history of childhood adverse experience, impulsive or antisocial dimensions or lower level of emotional maturity. Whether they precede or follow serious involvement with addiction, these characteristics are commonly observed to correlate with both most of the substance misuse and some of the behavioural addictions. Crucially, in TCs, a change for the better in these characteristics is thought to be essential for long-term recovery.

From the TC perspective, for recovery to occur a change in lifestyle, in addition to social and personal identity, is considered vital. Thus, the main psychological goal of treatment is an attempt to change negative patterns of thinking, behavior, and feeling that predisposes an individual to addictive behaviours; meanwhile the main social goal is to develop skills, attitudes, and instill values necessary for a responsible, addiction-free lifestyle. Stable recovery, however, is dependent on a successful integration of these psychological and social goals. Without insight behavioral change is unstable; however, without lived experience mere insight is insufficient.

3. View of the Right Way of Living

The third aspect deals with the conceptualization of a "right way of living." It's not just about abstaining from substances or addictive behaviours; it's about embracing a lifestyle that promotes health, responsibility, and social productivity. The TC model advocates for a balanced life, where individuals are encouraged to develop new, constructive patterns of behaviour and thinking. This involves learning skills like effective communication, emotional regulation, and problem-solving, which are crucial for maintaining long-term recovery and leading a fulfilling life.

Several key assumptions underlie the recovery process in the Therapeutic Community:

Motivation

Recovery depends on pressures, both positive and negative, to change. For example, certain people might seek help due to stressful external pressures; others may be moved by more intrinsic factors. For everyone, however, sticking to a treatment program requires a continual internal motivation to change. Thus, some elements of the treatment approach are designed to either sustain motivation or enable early detection of signals that the subject might terminate treatment prematurely.

Self-Help and Mutual Self-Help

In practical terms treatment is not provided per se; rather, it is provided to all individuals in the TC through the daily regimen of groups, workshops and meetings and its staff and peers. The efficacy of these elements, however, depends on the individual: they must engage fully in the treatment regimen for best outcomes. In self-help recovery the individuals must make the main contribution to their change process. By contrast, in mutual self-help the primary messages of personal growth, “right living”, and recovery are mediated by peers through discourse and sharing experiences in groups, providing examples as role models, and acting as encouraging, supportive friends in daily interactions.

Social Learning

Lifestyle changes occur in a social context. Negative behavioural attitudes, patterns, and roles, in general, are not acquired in isolation, nor can they be ameliorated in isolation. Thus, this presupposition is the basis for the view that a peer community can facilitate recovery. Social responsibility as a role is learned by acting the role within a community of one’s peers.

TCs adhere to certain values, precepts, and a social perspective that guides and reinforces recovery. For instance, there exist community sanctions that address antisocial attitudes and behaviour. Positive values, by contrast, are given a positive emphasis as being essential to both social learning and personal growth. These values include such concepts as truth and honesty, a strong work ethic, a feeling of responsibility for others , a sense of achievement and that all rewards have been earned, self-reliance, personal accountability, community involvement, and social manners. The values of “right living” are reinforced constantly in various informal and formal ways.

4. Community as Method

Finally, the most distinctive aspect of de Leon's theory is the concept of "community as method." This innovative approach uses the community itself as the primary agent for change.

The definition of community as a method offered by theoretical writings is as follows: The purposive use of the community to teach individuals to use the community to change themselves. Thus, the fundamental assumption that underlies the concept of community as method is: individuals obtain maximum educational and therapeutic impact when they engage in, and learn to use, all of the diverse elements of the community as tools for self-change. Therefore, “community as a method” means that the community is both context and mediator for individual change and social learning. Its membership establishes expectations or standards of participation in the community. It assesses how individuals are meeting these expectations and respond to them with strategies that promote continued participation.

Members live and work together, creating an immersive environment of mutual support and accountability. The community setting provides a safe space where individuals can practice new behaviours, confront their issues, and receive feedback and reinforcement from peers and staff. This continuous interaction within the community is what drives the transformative process in TCs.

Integrating the Four Views

The integration of these four views offers a robust and dynamic approach to addiction treatment. By addressing the disorder holistically, recognizing the individual's capacity for change, advocating for a healthier lifestyle, and utilizing the community as a therapeutic agent, TCs provide a comprehensive framework for recovery. This model acknowledges the complexity of addiction and the need for a multifaceted response that addresses all aspects of the individual's life.

The fundamental, primary foundation for the TC program model, its distinctive methodology, community as method, and its longer than usual treatment duration is the recovery perspective. Fundamentally, multi-dimensional (“whole person”) change necessarily requires a multi-interventionist approach that is sustained for a sufficient amount of time.

The practical application of these four views has shown promising results in long-term recovery outcomes. Studies have indicated that individuals who participate in TC programs often experience significant improvements in various areas of their lives, including reduced substance use, improved mental health, enhanced social functioning, and increased employment opportunities. The success of this model lies in its ability to effect deep-seated behavioral and attitudinal changes, fostering sustainable recovery.

Despite its effectiveness, the TC model faces challenges, particularly in integrating into broader healthcare systems and addressing diverse populations with varying needs. However, the evolving understanding of addiction and the increasing emphasis on holistic and community-based approaches in healthcare provide an opportunity for TCs to expand their reach and impact.