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CLUES TO THE FUTURE OF
THE TC
Enhancing Clinical
Potency
By Peter Provet, Ph.D.
President, Odyssey House
As the central
protagonist of group-based drug treatment, TCs lead the way in harnessing the
power of group dynamics to exert individual change. Evolution of the model
calls for maximizing the clinical potency of the TC group methodology as we
continue to integrate other clinical approaches into the treatment regimen.
Opportunities include
utilizing time more efficiently by re-examining how clinical intervention takes
place on a 24 hour, 7 days a week basis, and providing on-site/co-located
services that ensure, for example, teachers and medical personnel are
knowledgeable of TC concepts and able to incorporate clinical directives in
their interactions with residents.
Also key is the
productive utilization of group transference where the group is identified as a
benevolent force with an attractive identity, and confrontation is used in a
strategic manner, with positive reinforcement far outweighing negative
reinforcement and punishment. This is further enhanced by a redoubling of
efforts to demonstrate core TC values of responsible love and concern, and by
helping individuals in treatment fill the vacuum created when addiction and
concomitant behaviors are removed.
Additional
efforts to maximize TC potency include: the integration of traditional
psychotherapy; fostering a more compassionate and transparent TC management
style; and capitalizing on the synergetic partnership of counselors in recovery
with those who are not. Clinical managers must also resist pressure from
licensing and funding bodies to move away from a peer leadership model in favor
of staff-led interventions, and become promoters (and role models) of emotional
sharing, healthy physical activity, and rigorous intellectual pursuits - a role
that further extends to promoting treatment efficacy to funders, policy makers,
and referral sources.
Let me now elaborate
further on some of these points.
Fundamentally, clinical
potency within the TC is maximized when its members achieve intrinsic
motivation.
In the US, entry into
treatment has increasingly relied upon criminal justice referrals and mandates
-- "alternative to incarceration." Depending on locality, such efforts have
become quite systematic with all relevant partners (e.g., judicial,
prosecutorial, defense) working in concert. This movement has been essential as
drug and alcohol abuse is now recognized more as a medical disease, rather than
a moral failing or criminal enterprise. Solidifying this critical shift,
however, will take many more years of research into the biological and genetic
correlates of addiction and ongoing public education.
Simultaneously, however,
this shift has placed greater pressure on treatment programs to motivate
clients to achieve sobriety and a meaningful recovery based on self-examination
and self-awareness. Stimulating initially dormant "intrinsic motivation" is now
more important than ever. If unsuccessful, the client simply "does his time" in
the TC rather than jail and returns to the community largely unchanged, primed
for relapse. As a result, most early treatment interventions can be best
conceptualized around the goal of shifting the addict's motivation from that of
extrinsic to intrinsic sources.
One unifying principle
around which this effort can be based may be thought of as enhancing group
transference. The individual enters the TC environment typically resistant to
change, negative, and certainly impressionable. The group environment,
represented by fellow peers, staff, the physical structure, operational
guidelines, and all elements of daily implementation must be logical,
consistent, and attractive. The perceived potency of the group should be great;
most importantly, however, in a benevolent form. For some residents, the
experience of the TC as authoritarian and rigid is a contributing factor in
early treatment drop-out.
Of course, achieving
initial behavioral compliance is essential. For the community which regularly,
if not daily, accepts and integrates new members, "fresh off the street"
individuals must comply and "act as if." Too often, however, our treatment
environments are perceived as hostile (conveniently re-framed as
"confrontational") with far too little "responsible love and concern." Shifting
this environmental tone need not sacrifice the critical behavioral underpinning
of the TC to offer both positive and negative feedback within the context of
earned reinforcement.
Of course, "tough love"
has its place in the TC. Through years of drug use and related addictive
behavior, the addict's defenses -- denial, projection, repression, grandiosity
-- dominate his personality and become rigid, often impermeable. A degree of "breakthrough" is essential if meaningful change is to occur. The issue is more
one of timing and technique. When and how is it best to assist this complex
process along?
A key to this particular
evolution may be management style. Here, the primary function of role modeling
in the TC may inadvertently limit this shift to a more embracing, more
compassionate TC. Direct line TC program managers and counselors, when queried
on their rough, "in your face" clinical style, all too often respond, "I give
it like I got it." Staff management style must model appropriate compassion,
benevolence, fairness, and integrity if the TC environment is to embrace and
welcome the addict and not just confront and belittle him.
While clearly not a
democracy, the TC should incorporate certain democratic principles to enhance
its clinical potency. At every level of TC management, decision-making should
be carefully examined. From work schedules to encounter group membership; from
weekend passes to seminar leadership; from menus to linen replacement -- when
handled openly, judiciously, representatively -- decision-making processes can
powerfully reinforce the clinical potency of the TC environment.
