Beyond the “black box” of the Therapeutic Community for substance abusers: A participant observation study on the treatment process

Abstract

Therapeutic Communities (TCs) for substance abusers are an effective recovery oriented treatment for residents who finish the program. Over the years, the TC approach has been challenged by changes in society and by new perspectives on treatment. Moreover, the therapeutic process that takes place in TCs is barely understood or documented, often referred to as the “black box” of TCs. In order to gain insight into this process, there is a growing demand for qualitative research. This article presents the findings from a participant observation study in a Belgian TC. The first author fully immersed herself amongst the residents of a TC peer group for three weeks. By interpreting naturalistic participant observation data through psychoanalytic theory on addiction and mentalization, the process of change is discussed. It is argued that the TC program challenges former substance abusers in terms of problems they have with affect regulation. This process is understood in terms of a growing ability to manage disturbing affective experiences in a more mentalized way. The frustrating and holding TC environment together with the TC tools provide the condition and techniques to make this process manifest. Limitations of the study and suggestions for future research are discussed.

• Mentalization
• process research
• participant observation
• qualitative research
• substance abuse
• Therapeutic Community

Notes

¹George De Leon's The Therapeutic Community: Theory, model and method (2000) is seen as the definitive reference text for drug-free TCs, where all aspects regarding the physical and social organization of a drug-free TC are described in a comprehensive way.

²For an overview of other theoretical explanations, see De Leon (2000).

³E.g. Steve Walker (director of The Ley Community, Oxford), Stuart Plant (department coordinator of Phoenix Futures, Oxford), Krysztof Krysta (Secretary of the Federation of Therapeutic Communities of Central and Eastern Europe), Daniel De Angelis (director of Una Nueva Oportunidad, Argentina), Holly Robinson (staff member of the Royal College of Psychiatrists’ Centre for Quality Improvement, London) and Chris Lemaitre (responsible of TC De Kiem, Belgium).

⁴Violation of rules is also expected in the TC: it provides the material for the residents’ therapeutic work. There is zero tolerance, however, for transgressing the cardinal rules, as this is considered a direct threat to the physical or psychological safety of the community. Such cardinal rules include “(1) no physical violence, threats of physical violence or intimidation against any person, (2) no drugs, alcohol or related paraphernalia, and (3) no sexual acting out, including romantic or sexual physical contact” (De Leon, 2000, p. 224).

⁵In other group sessions, such as the bio-energetic group, residents attempt to trigger their own emotions by first expressing vehemently the words of the emotion, for instance: “I am angry! I am angry!! I am angry!!!” as if the triggering of an emotion by expressing it in a particular way actually realizes the emotion.

⁶The reason why new residents are asked to change their bank account has to be understood as another aid to recovery, by diminishing easy access to money to buy drugs. When residents are having a hard time during the treatment, they have more chance of staying and continuing their process when they do not have easy access to money.

⁷Whether it is an informal naturalistic group (e.g. a family) or a more formal group that is created because of a common goal (e.g. a school class, a team of colleagues).