Therapeutic Communities (TCs)--How some are thriving, some are dying off...and why

Daytop was one of the first therapeutic communities in the nation, and for many years, one of the most respected. Over the past couple decades, however, it appears to be in decline. Referral sources are holding back on sending clients there, financial problems have resulted in widespread layoffs, and rumors abound about poor quality treatment.

Yet the original notion of "community as method," which spurred the original TC movement in the 1960s, is still very relevant. Instead of the Betty Ford Center-kind of approach to treatment, TCs traditionally are more confrontational, less "cushy," and focus on two things: Your peers in treatment are the ones who can help you most (community as method of change) and Personal Responsibility. Everyone must work in a TC and the work (in kitchen, housekeeping, office, etc.) is considered part of learning to be responsible and carry one's weight. The underlying motivation for TC approaches is so "right on." So how has it gone so wrong and fallen into such disrepute?

1) Many of the original TCs (like Daytop) stayed foolishly loyal to "old ways" of doing things and failed to take into consideration what the research was showing. Very little "evidence-based" treatment in some of the old TCs.

2) Original recovering addicts who ran the TCs back in the 1960s and 1970s were promoted through the ranks (at least in Daytop) and became eventually top administrators. This failed to bring the most talented possible people into administration, because the person who came through the program and came up through the ranks was most often given priority for promotion over "outsiders."

3) Because there was little oversight or questioning of the TC strategies of heavy confrontation, sitting on metal chairs, learning experiences, "haircuts," etc., there arose abuses of power, many of which were protected rather than weeded-out.

The end result of these things in the TC movement was to retard the growth and renewal of such a great approach (community as method / personal responsibility).

I'd love to hear from people who are managing or working in therapeutic communities which have not fallen into the above traps but have evolved in a healthy, effective manner. I'd also love to hear from people who have observed some of the same things I have about the therapeutic community movement which are NOT working..

Why learning to "pull your punches" (manage your anger) is so crucial to relapse prevention

There is a clear connection between anger problems and chemical addiction. The two feed each other in so many ways. People we interviewed for our Pulling Punches: a Curriculum for Rage Management DVD series described the connection in different ways:

• "I used drugs like pot or heroin to stuff down or "numb" anger so it wouldn't come out."
• "I used alcohol to explode the anger out or get "false courage" to express myself."
• "Getting into an argument with someone was an excuse for me to use. It was like, 'You pissed me off, so I'm going out drinking.'"
• "I would cycle from rage, to using, to acting-out violently, to guilt afterward, to using again. ('I've done it again, I'm bad, I might as well drink and drug to forget the pain.'")

Of course, if you use drugs or alcohol often enough to numb your feelings, or as an excuse to act them out, you're likely to develop an addiction to those substances. And if the only way you can express your anger is when you are under the influence, you're going to want to use a lot, setting yourself up for addiction. So anger problems and chemical addictions feed each other. Not dealling with the anger problem sets our clients up for relapse. Because when they get angry during early recovery (which they surely will), if not prepared, they can easily relapse.

There is also an obvious connection between anger problems and incarceration. A very high percentage of those in jail or prison have histories of destructive anger patterns, and often it was some manifestation of rage which led to incarceration, including assault, spousal abuse, child abuse, murder, attempted murder, weapons charges, etc.

Most anger problems stem from feelings of powerlessness. Often, people who haven't learned more effective ways of setting boundaries (or who have grown up in environments where they had no control or ability to take care of themselves) resort to the only way they know how to retain some sense of "power:" physical and emotional violence. But, of course, because of the consequences of this approach, it becomes a vicious cycle: You feel powerless and helpless; you act-out aggressively; you enjoy a temporary (false) sense of control; but you ultimately lose power over your life. Because life can become more and more unmanageable as the result of anger problems: Jobs can be lost, kids taken away, relationships ended, and addictions fueled.

That's why we developed our DVD series: Pulling Punches, a comprehensive curriculum for anger management--specifically designed for people in recovery from addiction. The truth is that anyone with an anger problem--even if he or she isn't an addict or alcoholic--can benefit from anger management work. Because the issues are essentially the same:

• Looking at any negative consequences of our anger style (do we alienate people from us? Lose jobs? Get arrested for assault? Scare the people we love?)
• Learning that destructive anger patterns are usually learned early in life
• Needing realistic, practical tools with which to control anger "in the heat of the moment."
• Needing long-term conflict resolution skills to replace the negative approach. These make us feel more personally effective and truly powerful! (Whereas going off in a rage actually robs us of personal power...it's a paradox!)
• Checking out any of our underlying beliefs that fuel rage. (Like, "everyone's got it easier than me." "Any attempt to correct me is disrespecting me." etc.)
• Learning to express other emotions besides anger, since anger is often the cover-up for feelings we're less comfortable with (like hurt, fear, sadness, rejection). We need a broader emotional "palette," in other words.

In Part I of our series, we introduce people who have had serious anger problems in recovery, but who have changed: The main teaching points our:

1. It's an anger problem when your anger is out of proportion, out of control, or violent.

2. Some people have "anger blackouts," when rage becomes so intense they feel like they're in another state of being.

3. Some people get a "high" from anger. This high consists of both an adrenaline rush and feelings of power and control (however fleeting!)

4. Many people with anger problems learned their anger style from role models who had anger problems.

5. Many people with anger problems were victims of some trauma as children and developed a lot of "walking around" (chronic) anger from that, which comes out as over-reactions to everyday incidents.

6. What triggers people with anger problems often has to do with past experiences which get re-played in the present. the old emotions get triggered, and the old anger (that belongs back there) gets played out in the present!

7. There is hope. Many recovering people have learned better ways of managing their anger and improved their lives as a result.

Check it out with a free preview of Pulling Punches. Or weigh in here on what you think about the connection between anger and addiction. Or share what you're doing to help your clients with this connection...

More about Pulling Punches and anger management in future posts. CU soon... ReelDonna

Same dis-ease, different drug

Multiple addictions. We know that many people don't have just one addiction, they have a cluster of them. Indeed, some addictions seem to go together. Sexual addiction is often associated with drug abuse; anorectics and bulimics are often compulsive exercisers. Some compulsive spenders are workaholics, and gamblers often overeat. One addiction seems to fuel the other.

As more and more people have found, stopping one addiction does not automatically "cure" others. In fact, it often results in the emergence of a new one. Like a bump in a rug, when it's flattened out in one place it simply pops up somewhere else.

What is the common denominator in every instance of addiction? It's not one particular chemical, then, or whether the substance causes withdrawal, or how specifically it affects the brain. All of these vary considerably from one addiction to another. But what's present in every case of addiction is the addict! It's our "dis-ease" within--our lack of ease--that renders us so vulnerable to addictions, not the substances or activities themselves. The true source of addiction lies within us.

What are our drug treatment programs doing to address multiple addictions?

If you're interested in this subject, check out the book I co-authored, Willpower's Not Enough by Arnold Washton and Donna Boundy, published by Harper-Collins.

12-step programs and "after-care" plans...

12-step programs: what do you think? While there are still many roads that lead to "Rome," let's face it: the 12-step programs have as good a track record, or better, than many professional programs. I've been thinking about what they provide, which seems to be everything from:

• Hope. Seeing others who are successfully dealing with their addiction means that recovery is possible.
• A non-judgmental support system.
• Feedback. "Two heads are better than one, providing they're not on the same set of shoulders."
• A spiritual foundation. Since addiction is fueled by a lack of meaning an purpose in life, the spiritual aspect of self-help programs can be an antidote.
• A chance to help others. Contact with beginners in the program is an great reminder of our continual vulnerability. and helping others gives our lives a greater sense of meaning.
• A sense of belonging. Since isolation fosters addiction, this is another antidote.
• A new framework for looking at the problem. By admitting "powerlessness" over the compulsive drive, one paradoxically begins to regain more control through the support of the program.
• Round-the-clock support. Where can you find a program that lets you call your counselor in the middle of the night? Self-help groups provide a telephone network 24 hours a day!
• No time limit on help. People can continue attending self-help meetings for as long as they wish (whereas professional treatment is usually time-limited)
• Free of charge!

What do you think? Do you introduce your clients to 12-step programs? Are there other supports in the community that you find helpful?

Can Drug Dealing be an Addiction?

So often, recovering addicts spend weeks and months in drug treatment programs and never address the one behavior most likely to pull them back into drug use and illegal activities: involvement in the drug trade. While few figures are available, anecdotally, I believe that perhaps as many as 1/3 of those in substance abuse treatment programs also had some involvement in drug sales. While in drug treatment, they may explore childhood traumas, anger problems, family issues, relapse triggers, but somehow never address the central issue of their past involvement in drug dealing.

Yet for an addict, a return to drug dealing is a virtual guarantee of relapse to drug use as well. Drug dealing itself can be an addiction, I believe, akin in some ways to gambling. The lure of "quick, easy money" and some past experience that reinforces this belief is almost too much to resist. (Especially for someone just out of rehab or prison, yearning to have "things" again, who hasn't much legal work history and the notion of working at minimum wage is tough to swallow...) In addition, drug dealing delivers a habit-forming adrenaline rush of excitement, access to sex, a kind of power and "respect," status, and material pleasures. It's a pretty powerful pull!

We at Reelizations made a ground-breaking video, Getting Out of the Game: The Trap of Drug Dealing to address this important subject. It includes interviews with former drug dealers who successfully made the break and "got out of the game," detailing the strategies they used to counter the inevitable pull back to the streets and dealing.

Love to know what you think about this topic. Most drug treatment programs don't address it at all. Yet many addicts through the years have told me this is their central addiction.

What is "Gender-responsive treatment?"

Hey, this is an issue I've been thinking a lot about lately, since I'm consulting at the moment for a women's treatment program. Really, this particular program has been a therapeutic community that just happens to be segregated by gender, so it's all women. But until now, it hasn't been designed to really be responsive to women's particular needs in treatment. So what IS a good women's program? I'd love to hear from you, especially if you're involved in a program you feel is really "gender-responsive" (either gender). Some of the things I think of about creating an effective women's program include these kinds of ideas:

• Inspirational and empowering environmental cues (pictures, sayings by women from history through contemporary, etc.)
• Good leadership among staff, positive role models
• Staff trained to understand the effects of trauma on so many women, and what this means for treatment... (like hypervigilence to being screamed at, etc.!)
• Good integration of a mental health component, since many women in residential treatment (at least) have co-occurring mental health concerns like depression, anxiety disorders, etc.
• Family involvement, support for parenting, etc.

What do you think makes a good women's treatment program? A good men's treatment program? Or do you think coed treatment is best??

Calling everyone "in the trenches" of addiction treatment!

Welcome to Addiction Treatment Central! This is a place in cyberspace where addiction treatment professionals of all modalities and persuasions can gether around a "virtual water cooler" and share thoughts, frustrations, challenges and strategies relevant to treating addictions.

Let me introduce myself and why I'm even doing this... My "reel" name is Donna Boundy, I'm author of Willpower's Not Enough (HarperCollins) and When Money is the Drug. I started in the drug treatment field, well, 30 years ago (yeah, do the math...). I'm also a partner in Reelizations, a video/DVD production company that specializes in good, relevent, "meaty" (raw, realistic) programs on recovery. OK, blah, blah, blah. There's more to find in my profile is you care...

OK, so some of the topics we'll debate and discuss in this blog could include...
Gender-responsive treatment--what is it? Does it make sense?

• The latest on Suboxone
• Therapeutic Communities--are they still relevant? Can they be changed? Should they be?
• Is drug-dealing really an addiction in itself?
• Why do Americans have this insatiable appetite for drugs, as Hillary Clinton noted?
• What really works in treating adolescents?
• Anger management for recovering addicts--why is it crucial?
• How urban inner-city addicts can avoid relapse, even in such a challenging environment with cues and triggers all around!
• Are the 12-step programs still the best aftercare plan of all?
• "Trauma-informed treatment" --what is it? Why is it important?

Hopefully, you the readers will contribute more ideas and topics. Where do you want to start?