(CA 3 – THERAPUETIC

MODALITY)
Introduction

 
Background The corrections-based therapeutic community (TC) is one
of the most described treatment modalities for (substance abusing)
incarcerated offenders. The origins and development of the therapeutic
community have been traced back to two independent
traditions: the American hierarchical concept-based TC and the British
“democratic” Maxwell Jones-type TC. Both branches have developed
independently, targeting different people and tackling diverse
problems.
 Aims to demonstrate that there are clear and undeniable similarities
between the ‘two’ prison-based therapeutic communities.

Method A comparative historical review of the literature and a

critical discussion and comparison.

The links between the democratic and hierarchic therapeutic

communities are summarized under five headings: social learning and
behavioral modification; permissiveness and modeling; democracy and
hierarchy; communalism and community as method; reality testing and
‘acting as if’.
 The correction-based therapeutic community (TC) is a widely
described treatment modality for (substance abusing) offenders). It
developed as a self-help movement for the treatment of substance
abusers; primarily using behavioral modification techniques. It
developed as a professional group work method to treat people
suffering from a range of psychiatric difficulties, primarily using social
learning principles.
Diversion Treatment
It is an organized effort to utilize alternatives to initial or continue
processing into the justice system. It implies halting or suspending
formal criminal proceeding against a person who has violated a law, in
favor of processing through a non-criminal disposition or means. It is
aimed at keeping people out of the regular criminal justice system and
particularly out of its institutional component.
It should be noted, however, that diversion should be applied only
on offenders whose behavior can be effectively deal with in the
community, and not for those who have inflicted a serious degree of
injury or death, or for individuals who have presented psychotic or
unmanageable needing institutional care.
Types of Diversions

I. Pre-Trial Diversion
1. Dispute, resolution program-mediation program which seeks to help
antagonistic parties resolve their disputes in face-to face confrontation.
2. Deferred prosecution-An arrested offender is screened to determine if
the problem can be handled through a formal diversionary program. If so,
project staff explains the program to the offender. In case the offender is
willing the court will be asked to defer formal charging. Prosecutor to
dismiss the case soon as the offender completes the program.
3. Treatment Alternatives to Street Crimes (TASC)- Designed to divert drug
abusers away from the criminal justice system to the jurisdiction of
agencies offering specialized services.
II. Pre-Trial Release
1. Field citation-Discretion of arresting officers to release on the spot
any misdemeanant who does not demand to be taken immediately
before the court. But presenting him when needed ordinarily 3 days
after apprehension and release.
2. Station house citation-Police officer bring the offender to the police
station and where the information provided by the offender is verified
to be correct, permits the arresting officer to release the offender.
3. Release on own recognizance-Release without bail and without
supervision at the honor of the offender to report for the investigation
or hearing as scheduled.
4. Third Party release-Release to a relative, friend or any guarantor
charged in the appearance of the offender is needed.
5. Conditional release- Release with condition and compliance like
court appearance of to remain within defined geographical area.
6. Monitored release-defendant required to keep pre-trial release
program, like informing program officer or address or continued
presence in a particular community by phone calls at prescribed
intervals.
7. Unsecured bail-Released without bail or deposit and required to paid
some only upon default.
8. Privately secured bail-Private organization provides bail for the
indigent defendants.
9. Percentage bail – offender deposits certain percentage amount of
bail (usually 10%) with the clerk of court, of which 90% is returned after
termination of the program.
10. Fully secured bail-Defendant, family or bondsman put up the bail.
Bondsman usually requires collateral so that if offender absconded the
bondsman pursued offender with warrant to bring offender back.
11. Supervised pre-trial work release- Permits partial release with
offender returning after day work.
Huber Law –Wisconsin (1913)- is a prototype of the work release
program. In its current form anyone sentenced for a crime: non-
payment of fine, contempt of court may be released to work a normal
40-hour a week, returning to jail in the evening or weekends. It no
longer discriminates women and recognizes home-making as a
legitimate employment for which an offender is release from the jail.

Earning accumulates are kept until release less deduction for room and
board at the jail, (Approx 1/3). Work release is generally used at the 6
to 12 months remaining sentence. (Fear or potential menace) In some
states excludes, sex offenders, sale of narcotics, notorious criminals and
participant in organized crimes.
Study release-(Training release)-Same as work release except that
offenders in study release are exposed to educational experiences
instead of work experience (college, high school, vocational). Such
shows less like to recidivate than those who have not experienced the
program.

Furlough-Temporary release for confinement, generally considered

overnight or longer Maximum-granted in family emergencies as both of
close relatives with of correctional offices. (Washington states allows)
minimum enjoys furlough without pending cases who have at least
serve six months of sentence 12 months or less. Furlough varying from
up to 30 days. (England, Scotland, Denmark, Switzerland, Germany and
Grace). Sweden had the most liberal policy to counteract the negative
effect of institutionalization.
Half-way Homes-accepts prisoners near the end of their sentence to
help them are slowly integrated into the free community. They offer as
a buffer between the rigidity of the correctional institutions and the
freedom life on the street. Some having sheltered workshop assigned
to new men of residents who have not yet been able to work in the
free community.

Drug and Alcohol Treatment Program-maybe residential or out-patient

basis.
Gaudenzia House (Washington State)-Individuals with alcoholic
problem may voluntarily consent to enter and others sent directly by
the court after being found guilty of an alcohol relayed offences. In
some cases, the use of methadone maintenance program during which
client are stabilized at the appropriate dosage of methadone thereafter
released to the community. Some required to report back. Ex-addict
staff members practice attack therapy to force newly admitted addicts
to confront their problems squarely and encourage them to throw of
addiction. Having been former addicts themselves they know the
deception and manipulation used by addicts to perpetuate their
addiction. Treatment depends highly on the strong desire to throw off
addiction.
Home Detention (Jefferson Country Kentucky)- Home detention allows
juveniles to live at home with their parents while receiving
counseling/supervision from youth workers. It provides service both
parents and youth directed to strengthen family ties, minimize expenses
and avoid negative effects that might occur from institutionalization.

Group Homes (Florida)- Foster homes in which parents become house

parents operating thereon mini-juvenile shelter facilities. The size of Group
Homes varies according to the amount of space available in the homes of
parent who agrees to accept juveniles under the program. Subsidies for
expenses were minimal since a Group Home parents are partly volunteers
and partly each group home is under a servicing as a liaison between
parents and the family Group Homes Program. Reduced Truancy,
recidivism, illegal drugs, destruction of property and abusive action.
THE DEMOCRATIC TC AND ITS APPLICATION IN
PRISON
The democratic TC is described as ‘a small face-to-face residential
community using social analysis as its main tool.’ Its origins can be
traced back to:

(1) the Northfield Experiments, which can be considered as one of the

first attempts to rehabilitate people (neurotic soldiers) by means of the
‘therapeutic use of groups’ and
(2) some experimental treatment units during and just after World War
II for neurotic soldiers and ex-prisoners of war.
Democratic therapeutic community
(1) two-way communication on all levels;
(2) decision-making on all levels;
(3) shared (multiple) leadership;
(4) consensus in decision-making; and
(5) social learning by interaction in the ‘here and now’,in
which the facilitator simply helps the participants to uncover the
knowledge from within the group, rather than introducing new
knowledge through teaching.
Described the democratic TC as having four central principles:
(1) Permissiveness: residents can freely express their thoughts and
emotions without any negative repercussions (in the sense of
punishment or censure).
(2) Democracy: all residents and staff members have equal chances and
opportunities to participate in the organization of the TC
(3) Communalism: face to face communication and free interaction to
create a feeling of sharing and belonging.
(4) Reality testing: residents can be, and should be, continually
confronted with their own image (and the consequent impact of that)
as perceived by other clients and staff members.
The democratic TC in prison
One major reform involved a thorough evaluation and screening of
inmates(residents) in a Reception-Guidance Centre, from which they were
allocated to the most suitable facility. During this process, a ‘base expectancy’
score, implemented as a predictor of recidivism (parole violation), was
calculated for each prisoner along with a social maturity rating.
Seven successive stages of interpersonal maturity characterize psychological
development. They range from the least mature, which resembles the
interpersonal interactions of a newborn infant, to an ideal of social maturity
which is seldom or never reached in our present culture’. These so-called I-
levels (levels of interpersonal maturity) were used to identify to what degree
residents were able to form relationships and to predict how they might
respond to treatment. ‘This is an interesting attempt to introduce a
classification system which promises to be more appropriate for a prison
population than any psychiatric classification yet devised.’
THE CONCEPT-BASED TC AND ITS APPLICATION IN
PRISON
A concept-based therapeutic community is ‘a drug-free environment in
which people with addictive problems live together in an organized and
structured way to promote change toward a drug-free life in the
outside community. Every TC has to strive towards integration into the
larger society; it has to offer its residents a sufficiently long stay in
treatment; both staff and residents should be open to challenge and to
questions; ex-addicts can be of significant importance as role models;
staff must respect ethical standards, and TCs should regularly review
their reason of existence.’
Parallel to the characteristics of the democratic TC, the following
principles can be summarized:
(1) Community: living together in a group and showing responsible
concern and belonging is the main agent for therapeutic change and social
learning.
(2) Hierarchy: daily activities take place in a structured setting, where
people ‘act as if’ they have no problems and where ‘older’ residents serve
as role models.
(3) Confrontation: negative behavior, which interferes with the community
concepts, values and philosophy is confronted and put to limit. During
confrontations in encounter groups all feelings can freely and openly be
expressed.
(4) Self-help: the resident is the protagonist of his own treatment process.
Other group members can only act as facilitators.
This brief flourishing of the TC model within prisons lasted until the early
1970s, when it began to lose momentum and several programs had to close;
although others continued for 10 many years.

To a certain degree, all concept-based TC in prisons are based on self-help

principles. Understanding and compassion is combined with discipline and
hierarchy. Life is structured on the basis of clear and consistent rules.
Increased authority and esteem can be gained by a corresponding increase in
responsible behavior. Feelings are expressed during emotional encounter
groups. Learning takes place through peer-group interaction. Experienced staff
and
ex-substance abusers function as role models. Values such as self-discipline,
non-violence, acceptance of authority and guidance, honesty and openness
are encouraged. Acceptance of limitations and earning of privileges leads
gradually to integration into society.
THE TWO THERAPEUTIC COMMUNITIES

The two movements were developed quite independently, although

early pioneers within both movements must undoubtedly have known
each other’s work to some degree. It is interesting that neither
individual had tried to approach the other of their own volition.
LINKS BETWEEN DEMOCRATIC AND HIERARCHIC TCs IN
PRISON
Social learning and behavioral modification
The hierarchical TC is generally characterized by a behaviorally oriented approach.

However, the democratic TC approach is to some extent also behaviorally oriented,

certainly within the strict and authoritarian regimen of the prison setting.
‘The therapeutic community regime incorporates a strong behavioral component,
whereby an individual’s actions are examined with surgical precision and
commented upon by the whole community.’ Hierarchy is found in democratic
therapeutic communities and vice versa. The hierarchic TC recognizes social learning
as one of its pivotal concepts today and, ‘social learning’ in the democratic TC can
be a hard and confronting process because it does not always portray a person the
way he would like to be seen.
Permissiveness and modelling
In a democratic prison-based TC, permissiveness provides prisoners with
greater freedom to act out, without consequent disciplinary action. Yet this
does not mean that everything is tolerated. Instead of being punished, the
resident is confronted by his peers and by staff with regard to the effects of
his behavior on them (the community). Talking about misbehavior in public
(generally within the community meeting), is often perceived by the
residents as more difficult than punishment, perceive permissiveness as a
facilitating principle within the process of disclosing honestly personal
feelings: ‘The sense of security which is engendered by the avowed
commitment to treatment objectives, and by the belief that the expression
of deviant attitudes and behavior will not automatically attract a formal
disciplinary response, entices inmates to display, conduct and divulge
information that they would otherwise suppress in a conventional prison’.
In a hierarchic prison-based TC, negative behavior is confronted freely
and openly in groups. After catharsis and openness, which can be part
of a painful process, older residents identify with the expressed
problems, serve as role models and encourage ‘right living’. This
includes certain shared assumptions, beliefs, and precepts that
constitute an ideology or view of healthy personal and social living. This
could be described as a deliberate imposition of roles on residents in a
top-down attempt to influence instinctive behavior.
Democracy and hierarchy
Democracy is often associated with freedom and responsible action. The
important far reaching difference between a staff member (who is actually
‘free’ to go home after duty) and the residents (who must remain) is
undeniable. Although participation in the therapeutic community is voluntary
at all times, giving the resident the freedom and the responsibility to quit the
programed at any time, the broader context of imprisonment (and often
coercive treatment) limits absolute freedom of decision.
In a hierarchically structured prison TC, freedom and responsibilities are
expressed by position in the structure. In this context, older residents have
more freedom. But there is also the prison framework and the confrontation
with the ‘absolute’ freedom of the staff. To counter this problem, an
adequate social and therapeutic climate of mutual understanding is crucial.
For the maintenance of therapeutic integrity in both types of therapeutic
community, it is thought best if they are isolated as much as possible from the
anti-social prison culture, and enabled to create their own alternative
community’.
Communalism and community as method within a prison-based therapeutic
community, ‘Communalism’ and ‘Community as method’ refer to a climate
and atmosphere in which the community as a whole is used as a therapeutic
force. Here, residents function as main agents of their own treatment process.
‘Self -help’ can be considered as the main therapeutic tool. Graduates of
hierarchical therapeutic communities remain a family, continually support
each other, promote a drug-free life and try to be role models to more
junior residents. Thus, an ideological surplus is added to the therapeutic
community, as the therapeutic community can be perceived as a treatment
modality a such as well as an ideology to decrease social inequity generally.
Communalism and community as method can pose specific problems in
correctional facilities. It is not always possible to react appropriately to
behavior according to the TC-methodology, where positive behavior is
rewarded by privileges. Security regulations are seen as paramount and
can impede a community-driven action. Points out that therapeutic
communities within prisons can only be successfully implemented
when security issues are accepted as fundamental task of corrections.
DISCUSSION OF THE SIMILARITIES AND DIFFERENCES
Recent literature emphasizes a gradual, but not to be underestimated,
tendency towards stressing the common features of the American
hierarchic drug-free (‘new’) and the or democratic (‘old’) therapeutic
community.

Some other similarities might be added:

(1) social learning is the key-concept within both types
(2) confrontation within concept-based TC is evolving towards more
dialogue, stressing the importance of equal and free communication
within both approaches
(3) both types of therapeutic communities (especially within
corrections) are considered appropriate by the prison authorities, at
least for those residents who have some motivation to change (4)
motivation to treatment is identified as a crucial concept especially
with regard to post-prison aftercare (post-prison aftercare is considered
extremely important in both types of therapeutic communities
(5) the challenges faced by both traditions are similar and both
types struggle with the employment of staff members, the treatment
versus security dilemma and both approaches are challenged by recent
developments in the delivery of managed care.
Therapeutic Communities and Treatment Research
Programs to treat drug abuse and addiction/dependence are a
relatively recent innovation. Drug abuse programs emerged in an
organized way in the 1960s as a response to this major social and public
health problem in the United States. Mainstream organized health care
was not prepared, either intellectually or organizationally, to respond to
the drug abuse epidemic; thus, an alternative system developed. The
growth of treatment facilities in the 1960s and 1970s reflected differing
views of the nature of
drug abuse and addiction and what was required to treat it effectively.
Aside from detoxification units, which were intended to provide the
first step in treatment but more commonly provided only a brief respite
from the rigors of addiction, three modalities emerged as the dominant
treatment types for drug abusers: drug-free outpatient programs;
outpatient methadone maintenance programs; and long-term, drug-
free residential programs called therapeutic communities (TCs). More
recently, short-term residential programs using 12-step or other non-TC
approaches have emerged.
TREATING DRUG PROBLEMS
This monograph grew out of a technical review meeting that took place
in May 1991. The technical review was convened by the National
Institute on Drug Abuse (NIDA) for the purpose of systematically
examining the TC modality and the existing body of research on TC
treatment, to review and consolidate knowledge about this modality,
and to chart future directions in TC research. While the TC is a major
modality that is unique in its view and application of treatment,
research in this modality also has implications for other modalities; in
fact, methods developed in TCs have been applied in other programs.
In addition to reviewing the TC research base to guide future lines of
investigation, the goal of the technical review was to involve the TC
movement’s practitioners to the greatest extent feasible. An essential
feature of research on treatment programs and modalities is the active
cooperation of practitioners as partners in the research enterprise.
These practitioners are in a position to facilitate the research, to offer
insights during its planning and conceptualization, to provide guidance
on critical issues and questions, and to provide feedback on analytic
interpretations.
As users of applied research, TC practitioners can help focus research so
that it is truly useful. Thus, it was decided to invite the Therapeutic
Communities of America (TCA) to attend the meeting, to form three
panels (research, clinical, and administrative), and to report back to the
group during the final phase of the meeting. Although the TCA reports
are not contained in this monograph, they were useful in developing
the recommendations contained in the final chapter.
TC PROGRAMS
TC programs reflect a view of the drug abuse client as having a social
deficit and requiring social treatment. This social treatment may be
characterized as an organized effort to reserialize the client, with the
community as an agent of personal change. There has been much folklore
and misinformation about TCs. They are viewed by some as isolated from
the mainstream of drug abuse treatment, antagonistic toward medications
in drug abuse treatment, and not generally receptive to research.
Regarding the first point, TCs have evolved from a self-help perspective as
a social movement. Because TCs utilize a social treatment approach, their
leaders and practitioners have not tended to have medical credentials.
Indeed, given their history and self-help perspective, TC staff (at all levels)
have included ex-addicts, social activists, and health professionals.
It should be noted that all drug abuse treatment modalities have evolved in a
rather short span of time, and TCs are generally accepted by practitioners in
other modalities as a legitimate treatment approach.

Existing drug abuse treatment modalities evolved in response to a need that

the mainstream health care system was not meeting, and the evolution of
these modalities is in the direction of integration. While medications, notably
methadone, are not generally part of TC treatment, some TCs permit
appropriate use of psychotropic medications under medical supervision, as
long as they do not pose a threat to the abstinence norms that are
therapeutically important. It also is important to note that, while many TCs
may not have research departments, much of the existing research in the drug
abuse literature was carried out in cooperation with TC programs. In fact,
some of the early landmark
studies on treatment effectiveness were carried out by TC researchers.
TCs tend to share a similar view of the client, an emphasis on structure
and hierarchy within the program, a need to isolate the individual from
competing influences during treatment, a need for a prolonged period of
treatment that is phased and intensive, and clear norms regarding
personal responsibility and behavior which form the core of treatment.
Learning, accepting, and internalizing these norms is accomplished
through a highly structured treatment process that requires active
participation by
the client in a context of confrontation (to address denial, false beliefs,
and defense mechanisms), mutual self-help, and affirmation of program
expectations. Thus, as De Leon points out in the following chapter,
community is treatment. The therapeutic process involves the group (the
community) constantly, but also must involve the individual. An aphorism
of the TC movement is, “Only you can do it, but you can’t do it alone.”
MAJOR AREAS OF FOCUS
Not all residential drug treatment programs are TCs, and it is not clear that all
TCs follow the same model. The existing programs that call themselves TCs
have an organized movement and both national (TCA) and international
(World Federation of Therapeutic Communities) levels.

What are the essential characteristics of a TC? De Leon (this volume) has
attempted to delineate a general theoretical model of the TC. The TC
perspective is reviewed in terms of its view of the disorder, the person, right
living, and recovery. Drug abuse is viewed as a disorder of the whole person,
and individuals are distinguished along dimensions of psychological
dysfunction and social deficits. Recovery is viewed as a developmental
process that requires the integration of explicit social and psychological goals.
What distinguishes the TC from other treatment approaches is the
purposeful use of the community as the primary method for facilitating
growth and change in individuals. There are four dimensions of behavioral
(objective) change: The dimensions of community member and socialization
are concerned with the individual’s social development; the developmental
and psychological dimensions refer to the evolution of the individual in
terms of maturity, emotional skills, and identity. The subjective aspects of
behavioral change are the individual’s essential perceptions and experiences
related to the following:
(1) circumstances (external pressures);
(2) motivation (inner reasons for personal change);
(3) readiness (treatment is the only option);
(4) suitability (self-perceived match between the person and the treatment);
and (5) critical perceptions of self-change (e.g., self-efficacy, self-esteem).
Essential experiences include healing experiences (nurturance, physical
and psychological safety); subjective learning experiences (self-
evaluative perceptions, thoughts, and feelings necessary for achieving
internalized learning); and critical therapeutic experiences (e.g.,
distinctive therapeutic events). The change process in the TC
incorporates behavioral and social learning principles with the essential
experiences and perceptions as mechanisms in the process. Change is
viewed from a behavioral orientation that includes the community as
trainer, efficacy training, social role training, and vicarious learning.
The stages of change are reviewed and distinguished along three perspectives:
recovery, the program, and treatment. The last stage of treatment, integration, is
an evolving process that begins in treatment; however, it emerges mainly after
separation from the program, which underscores the interrelation between TC
influences
and broader life experiences. Integration is the last phase of the learning process,
which is preceded in order by compliance, conformity, and commitment. A
distinctive marker of the integration stage is a change in identity that is perceived
by the individual and others. This change in identity reflects the importance of
learning that is internalized and that characterizes the integration phase.
In addition to clarifying the TC as a model and recognizing that different varieties
exist, it is important to examine a range of questions about client populations
served, services and treatment processes, cultural aspects, and outcomes. Issues
of planned change and the potential of science to improve the TC modality also
are of interest.
Some fundamental research issues that need to be
considered include:
(1) delineation of the guiding principles
and practices that distinguish the TC field;
(2) the role and impact of
integrating professionals into the TC;
(3) description of the spectrum of
clients in treatment;
(4) reassessment of recommended lengths of stay in relation to client
characteristics and the different varieties of treatment experience; and
(5) identification and description of the range of treatment and rehabilitative
services offered in TCs.
Comprehensive, holistic treatment approaches employing
multidisciplinary teams within the TC are required to address the
multiplicity of needs of today’s clients. In addition, the importance of
developing new models of addiction and recovery are emphasized.

Three major fields for practical application of the AGA

method:
(1) to identify individual and treatment variables that are related to client
success;
(2) to monitor client progress along relevant dimensions, (e.g., self-
image, perception of harmful substances); and
(3) to provide empirical insights into perceptual and motivational
dispositions, which are valuable in therapy and counseling.
At one level, it may be seen as a complication of treatment decisions,
but it is so ubiquitous that it is viewed as a normal part of the array of
treatment tasks. Suggests that changing trends in drug abuse patterns
and drug users seeking treatment have highlighted the importance of
considering psychological and psychiatric factors in the treatment of
substance abuse.
Specific psychiatric disorders, including depression, antisocial behavior,
and borderline personality, appear to occur more frequently among
drug users. Psychological symptoms, as distinguished from psychiatric
disorders established by diagnostic criteria, are generally more
transient and often may be situationally induced. The psychological
profiles of admissions to TCs reflect high levels of depression and
anxiety, poor socialization, deviant Minnesota Multiphasic Personality
Inventory
(MMPI) profiles, and low self-esteem. Psychological improvement is
shown by clients who are reexamined during treatment. Post-treatment
psychological status is related to clients’ length of stay in treatment,
with greater improvement seen among those who stay in treatment
longer (De Leon 1984). Favorable social adjustment also is associated
with significant psychological improvement at follow-up.
The development of a nosological system to classify disturbances
descriptively and the development of structured instruments to obtain
the diagnoses have facilitated the investigation of the prevalence of
psychiatric disorders among substance abuse populations.
Three lessons from history guided changes in later prison-based TCs:
(1) improved communication between TC and non-TC institutional
personnel;
(2) improved security; and
(3) maintenance of control by staff.
Effective TC intervention would involve a process involving three stages
that correspond to the inmate’s correctional status (i.e., incarceration,
work release, and parole or other surveillance).
The primary stage should occur in prison, where there is the time and
opportunity for comprehensive treatment.
The second stage is a transitional TC, providing a therapeutic and
prosocial milieu for individuals on work release.
The third stage, when the client is back in the free community, involves
counseling, group therapy, and participation in transition program
activities.
Drug abuse treatment has evolved over a relatively short timespan,
with most of the existing programs emerging over the past three
decades. A variety of perspectives have guided the development of the
modalities now available, and the TC approach stands in contrast to the
medications-based programs such as methadone maintenance and
many of the outpatient counseling programs. The TC modality
represents a major approach to treatment that emphasizes intensive
treatment involving a social perspective and is rooted in a specific view
of the disorder, the person, right living, and recovery. It is a high-
demand approach, which is not suitable for all clients.
Like other modalities, the TC field has developed and undergone
change. The field of drug abuse treatment has become increasingly
complex over the past decades, and the TC movement has responded
by becoming diversified. The TC has been adapted to a variety of
environments, and it has been modified in ways that make it better
able to serve the needs of clients who present with a greater range of
problems, including child care responsibilities, issues of gender and
minority cultures, homelessness, psychiatric co-morbidity, criminal
justice involvement, and HIV issues.

An important part of the review presented here is to examine the range

of clients served, the needs of client populations, and the ways in which
the TC field addresses those needs as a dynamic and evolving modality.
WHAT IS TC?
The Therapeutic Community (TC) is an environment that helps people
get help while helping others. It is a treatment environment: the
interactions of its members are designed to be therapeutic within the
context of the norms that require for each to play the dual role of
client-therapist. At a given moment, one may be in a client role when
receiving help or support from others because of a problem behavior or
when experiencing distress. At another time, the same person assumes
a therapist role when assisting or supporting another person in trouble.
HOW DOES TC LOOK LIKE?
The operation of the community itself is the task of the residents,
working under staff supervision. Work assignments, called “job functions”
are arranged in a hierarchy, according to seniority, individual progress and
productivity. These include conducting all house services, such as cooking,
cleaning, kitchen service, minor repair, serving as apprentices and running
all departments, conducting meetings and peer encounter groups.

The TC operates in a similar fashion to a functional family with a

hierarchical structure of older and younger members. Each member has a
defined role and responsibilities for sustaining the proper functioning of
the TC. There are sets of rules and community norms that members upon
entry commit to live by and uphold.
WHAT ARE THE SALIENT FEATURES OF TC?
The primary “therapist” and teacher is the community itself, consisting of
peers and staff, who, as role models of successful personal change, serve as
guides in the recovery process.

TC adheres to precepts of right living: Truth/honesty; Here and now; Personal

responsibility for destiny; Social responsibility (brother’s keeper); Moral
Code; Inner person is “good” but behavior can be “bad”; Change is the only
certainty; Work ethics; Self-reliance; Psychological converges with
philosophical (e.g. guilt kills)

It believes that TC is a place where: One can change – unfold; the group can
foster change; individuals must take responsibility; structures must
accommodate this; Act as if – go through the motion.
There are 5 distinct categories of activity that help promote
the change:
• Relational/Behavior Management
• Affective/Emotional/Psychological
• Cognitive/Intellectual
• Spiritual
• Psychomotor/Vocational-Survival Skills
These tools serve more than just the purpose of curbing unproductive
behavior. They are also a means used for enforcing community
sanctions on behavior that undermine the safety and integrity of the
community such as violations of the cardinal rules of TC: NO drugs, NO
violence or threat of violence, NO sexual acting out and NO stealing!
Everything an officer does is meant to erase “street behavior” and to
lead the offender to be committed to “right living”.

When the office gives seminars and tutorials, arranges activities

focused on the Higher Power, conducts games, educational trips and
other recreational activities, we touch on the TC aspect of Intellectual
and Spiritual Dimension. Aside from the role of a direct supervisor, the
VPAs may be the invited resource persons, donors/sponsors,
facilitators, lecturers, etc. during these seminars.
The skills training and livelihood activities fall within the purview of TC’s
Vocational and Survival Skills, so with Medical/Dental Clinics and
Environmental Conservation activities. In this aspect, the VPAs can
facilitate job placement and can tap community resources for clients
social and physical needs.

Therapeutic Community is a tool that the Administration uses to

prepare the client for reintegration to the community as a reformed,
rehabilitated, productive, drug-free and law abiding person.
WHAT IS THE TC MISSION?
To promote human and social transformation among our clients and
among ourselves.

WHAT IS THE TC VISION?

By the end of this decade, TC shall have become the corporate culture
of the Parole and Probation Administration permeating its plans,
programs, and practices, and confirming its status as a model
component of the Philippine Correctional System.
6 Types of Group Therapy

There is no way around it. Recovery is up to us. We cannot expect

anyone else to take the mantle of sobriety for us. Getting and staying
clean starts and ends on our own shoulders. That said, no recovering
addict is an island—thank goodness. In fact, if you try to do it alone,
you are far less likely to make it for the long haul. Lasting recovery
happens in community and group therapy is one of the best ways to
keep that going in your life.

Support, feedback, encouragement, someone to call at one in the

morning when the cravings are clawing at our brains, these are just a
few of the benefits of group therapy.
Beyond that, group therapy helps those in recovery put into practice
the essential life skills they need to adequately take care of themselves
on a daily basis. Plus, they help out with understanding healthy and
effective communication skills we need to repair the relationships we
might have damaged with our destructive behavior as well as create
new friendships.
The following are six types of group therapy that are
popular in drug treatment programs and beyond.
1. Psychotherapy Groups
Group psychotherapy is based on the understanding that the
relationships that are built between people are necessary to regulate
all aspects of daily living. These groups focus on what members can do
in the here and now and help members work together to form a
cohesive group in which they can freely share their victories and
setbacks in a safe and supportive environment.
Therapists that use psychotherapy in a group setting must practice
empathy in order for individual group members to communicate freely
with each other. These groups help those new in recovery build the
interpersonal skills they need in order to effectively communicate with
others in a healthy manner.
2. Cognitive Therapy Groups
Another popular type of group therapy in drug treatment is cognitive
therapy groups. As its name suggests, these particular groups use
cognitive behavioral therapy and other similar therapy styles that will
help newly recovering addicts identify patterns of behavior that have
kept them stuck in their substance abuse.

Therapists in cognitive therapy groups work with clients to control their

thought processes and their addictive behaviors and help give them the
tools to cope with the stressors and triggers they encounter in a more
proactive fashion and without having to resort to the use of drugs and
alcohol.
3. Dynamic Group Therapy
Dynamic group therapy is yet another popular therapy option that drug
and alcohol rehab facilities use to help addicts address and overcome
addictive behaviors. This form of addiction group therapy focuses on an
addict’s deficits in both regulating their own behavior and any defects
in character the addict may possess. Dynamic group therapy gives
clients the supportive environment to examine the common issues that
are shared within the group. This cohesiveness allows each member to
overcome feelings of isolation and shame, as well as establish a safe
environment with the goal of learning how to effectively control their
emotions and feelings and achieve abstinence.
4. Relapse Prevention Groups
As a person successfully completes a drug treatment program, they may feel
their recovery journey has come to an end. In reality, the real work in
recovery truly begins once an individual transition back into their normal daily
routines. The first few months of recovery is when addicts are at their most
vulnerable, and it is important for people new in sobriety to have the extra
support needed to make this transition much easier.

Relapse prevention support groups are a major fixture of aftercare programs

and are designed to help clients identify the triggers in their environment that
have the potential to lead them to relapse. In these groups, clients work on
refining coping skills and lean heavily on peer support, continued involvement
in 12-step groups, and the utilization of educational programming that will
help addicts better understand the chronic disease of addiction.
5. Mutual Self-Help Groups
Perhaps the most common, effective, and popular type of group
therapy outside of an intensive treatment program are mutual self-help
support groups such as Alcoholics Anonymous. Many drug and alcohol
treatment facilities base their programs and services on 12-step
philosophy, and active participation within these groups is paramount
in helping the individual overcome their addiction.

These self-help groups are made up of people who share a common

condition and a common goal. Outside of residential treatment, AA
groups are self-run and offered in large groups, small groups, and other
meeting types. These meetings are free of charge and focus on mutual
support and the achievement of abstinence.
6. Network Therapy
A big indicator of success in sobriety is the presence of a substantial
support network comprising of family and friends who are fully
supportive of a person’s decision to lead a recovery-based lifestyle.
Network therapy involves using the social network of the newly
recovering addict in a group format to provide support for behavioral
change and relapse prevention.

Cognitive-behavioral therapy provides the foundations for network

therapy, and its ultimate goals are to help clients achieve and maintain
their hard-earned sobriety. It is believed that participation of
individuals who are part of the patient’s network of relationships can
enhance the outcome of treatment.
Group therapy is one of the essential foundations of an effective
individual plan of recovery. When you choose to undergo drug
treatment at First Steps Recovery, our experienced addiction
professionals can use a wide variety of group therapy options in order
to individually tailor a program that means your unique and specific
needs. If you or a loved one needs professional help in dealing with
your substance abuse issues, pick up the phone today and call First
Steps Recovery: 844-244-7837. Make recovery a reality.
DIVERSION PROGRAM
"Pretrial intervention program" redirects here. For the program specific
to New Jersey, see Pretrial Intervention Program.
A diversion program, also known as a pretrial diversion program or
pretrial intervention program, in the criminal justice system is a form of
pretrial sentencing, in which a criminal offender joins a rehabilitation
program to help remedy the behavior leading to the original arrest,
allow the offender to avoid conviction and, in some jurisdictions, avoid
a criminal record. The programs are often run by a police department,
court, a district attorney's office, or outside agency.
Problem-solving courts typically include a diversion component as part
of their program. The purposes of diversion are generally thought to
include relief to the courts, police department and probation office,
better outcomes compared to direct involvement of the court system,
and an opportunity for the offender to avoid prosecution by completing
various requirements for the program.

These requirements may include:

Education aimed at preventing future offenses by the offender

Restitution to victims of the offense
Completion of community service hours
Avoiding situations for a specified period in the future that may lead to
committing another such offense. Diversion programs often frame
these requirements as an alternative to court or police involvement or,
if these institutions are already involved, further prosecution.
Successful completion of program requirements often will lead to a
dismissal or reduction of the charges while failure may bring back or
heighten the penalties involved. Charges dismissed because of a
diversion program will still lead to additional criminal history points
under the US Sentencing Guidelines if there was a finding of guilt by a
court or the defendant pleaded guilty or otherwise admitted guilt in
open court, provided that the deferred disposition or deferred
adjudication was not a juvenile matter.
Diversion and juvenile justice

Diversion has played a key role in improving outcomes and

rehabilitating youthful offenders. The concept of juvenile diversion is
based on the theory that processing certain youth through the juvenile
justice system may do more harm than good. Programs meant to divert
juvenile delinquents are often fundamentally different from the
programs meant for adults. Many times youth will present with
substance abuse and mental health issues which may be the underlying
cause of such delinquency.
A Juvenile Diversion program has the ability to be used as an
intervention strategy for first time offenders who have broken the law
and found themselves in the juvenile justice system ("Juvenile Diversion
Programs"). There are many benefits to this program that include,
avoiding the child from being influenced by more serious criminals in a
juvenile detention center, allowing the courts to use resources that are
needed for those juvenile delinquents who are an actual threat to the
society, and getting the child help with drug addiction or family issues.
In the United Kingdom
Diversion can ensure that people with mental health problems who
enter (or are at risk of entering) the criminal justice system are
identified and provided with appropriate mental health services,
treatment and any other support they need. In the UK, Centre for
Mental Health has shown that such diversion represents good value for
money, with well-designed intervention helping to reduce reoffending
by a third. The need for joined-up services was the focus of a Centre for
Mental Health lecture in 2011, in which NHS Confederation Chairman
Sir Keith Pearson emphasized the need to use custody more effectively
and divert those who need it into treatment.
In the United States
The availability of diversion programs depends upon the jurisdiction,
the nature of the crime (usually non-violent offences) and in many
cases the exercise of prosecutorial discretion. A 2016 The New York
Times investigation revealed that some prosecutors charged substantial
fees for, and received significant revenue from, diversion programs.
Those fees can operate as a barrier to impecunious defendants
accessing diversion. Pleading guilty is often a prerequisite to access to a
diversion program. This means that if a defendant proceeds to a
diversion program, then fails to pay the fee for the program, the
defendant can be brought back to court and proceed directly to
conviction and sentencing.
Some jurisdictions in the United States may provide diversion programs
for drunk driving charges. One such program is the Victim Impact Panel
(VIP) administered by Mothers Against Drunk Driving (MADD) since
1982. MADD typically charges a $25 "donation" (which is defined as
voluntary), even for court-mandated attendance; MADD reported
$2,657,293 one year for such donations on its nonprofit tax exempt
returns.

In Florida, several counties offer a diversion program for veterans of the

U.S. Armed Forces. Those who qualify and complete the program will
have the criminal charge dismissed and can get the case expunged from
their record.
In Georgia (Country)
Diversion program gives one chance to a first time offender juvenile to avoid
criminal record and conviction in exchange for the commitment to comply
with a specific set of requirements. The purpose of the obligatory activities is
to positively influence the offender and help him/her to become a better
citizen for the society.

The decision on juvenile diversion is taken by the prosecutor/attorney. A social

worker is then assigned to the case to assess the bio-psycho-social profile of
the juvenile. At the end of the assessment, the social worker recommends a
set of requirements to be included in a diversion contract. The mediation
process initiates with the victim's consent. A neutral/independent mediator is
assigned to the case. The mediator's tasks are: facilitating dialogue between
the offender and the victim, helping the reconciliation process and reaching an
agreement on damage restitution.
 Deferred prosecution

An intervention is a combination of program elements or strategies designed

to produce behavior changes or improve health status among individuals or
an entire population. Interventions may include educational programs, new
or stronger policies, improvements in the environment, or a health
promotion campaign. Interventions that include multiple strategies are
typically the most effective in producing desired and lasting change.

Interventions may be implemented in different settings including

communities, worksites, schools, health care organizations, faith-based
organizations or in the home. Interventions implemented in multiple settings
and using multiple strategies may be the most effective because of the
potential to reach a larger number of people in a variety of ways.
Evidence has shown that interventions create change by:
influencing individuals’ knowledge, attitudes, beliefs and skills;
increasing social support; and creating supportive environments, policies and
resources.

EFFECTIVE CORRECTIONAL PROGRAMMES

There are a wide variety of programs that purport to provide effective
treatment for the needs of offenders. However, only programs that have been
evaluated with appropriate research methodologies and which demonstrate a
reduction in recidivism should be considered for implementation. Many
programs have been designed without adherence to the principles of risk,
need and responsivity, and therefore may not provide the most effective
treatment.
 
To determine which programs are most likely to produce reductions in
recidivism a number of authors have conducted extensive reviews of the
programmed outcome literature through the use of meta-analysis. The results
from these reviews suggest a set of characteristics that can be used to judge
the quality of a programs.

While research has shown positive effects of treatment on offender behavior

there remains a need for high quality research to support and further guide
programs developers. In particular, programs research is needed to
demonstrate which programs are effective across cultures and to identify those
programs characteristics that may be sensitive to cultural differences. In
addition, not all correctional jurisdictions are able to put in place extensive
programming regimes and research is needed to demonstrate the best
approaches to use when resources are limited.
WHAT WORKS IN PROGRAMMING

Meta-analysis has also been used to identify the programs elements that are
most likely to have an impact on recidivism.

Programs they evaluated into one of four treatment groups:

(i) Criminal sanctions:

Studies in which there was a variation in the sentence, but no variation in the
rehabilitation component. In these studies, options comparing more vs. less
probation, or probation vs. incarceration were compared to determine which
produced a lower rate of recidivism.
(ii) Inappropriate correctional service:

These studies were not consistent with the risk/need principles. These studies
provided intervention for low risk offenders and used non-directive
relationships based on psychodynamic counselling. Other kinds of
interventions included in this group were group counselling programs that did
not use pro-social modelling, non-directive educational and vocational
programs and programs like Scared Straight, designed to discourage continued
criminal activity by showing what prison is like.

(iii) Appropriate treatment:

These options included delivery to higher risk offenders and used behaviorally
oriented interventions.  
(iv) Unspecified treatment:

This was the fourth category and was used where the treatment was
unspecified, or could not be classified as either appropriate or inappropriate.

The authors compared the recidivism results across the different programs
types and the results of the analyses are summarized in Table 5. The
effectiveness measure used was the Phi coefficient, a measure of association,
in this case demonstrating the impact the program type had on recidivism. A
positive number indicates the program decreased recidivism, while a negative
number indicates the program increased recidivism.
Listed below are the principles, with examples of how they
are applied in programs currently being delivered at the
Correctional Service of Canada:

1. The risk and need levels of offenders are specified and used in selection of
participants and criminogenic needs are targeted. Offenders admitted to the
Correctional Service undergo an extensive assessment of their risk and needs.
Risk is assessed by both dynamic and static risk factors to identify those
offenders most in need of programming. The areas of programming they
require are identified by the needs assessment and only those needs identified
as relevant to the offender are addressed through programming. The
assessment takes between two and three months and includes a review of
court and police documents, interviews with the offender, and specialized
assessment in areas such as substance use, education and learning, mental
health, sexual offences and violence.
2. Programs are highly structured with content and contingencies under the
control of the facilitators, not the participants, and antisocial attitudes are not
reinforced. All programs have structured manuals that define the objectives and
activities for each session. Program facilitators must follow the defined program
and must not change how the components are taught. All of the program
components are covered consistently every time the program is completed and
participants are unable to lead the program off-track to meet personal goals
that may be inconsistent with the program goals.

3. Account for the response rate of participants. For example, highly structured
programs are most appropriate for offenders who are not effective at
conceptualizing ideas; higher levels of interpersonal interaction are required for
high anxiety offenders; and additional contingencies are put in place for
offenders who have low motivation.
Core programs are cognitive behaviorally based to meet the learning needs
of offenders. They include skill development exercises that make use of role
playing and practice. In addition, specialized program options are available
for women and Aboriginal offenders. These programs address the different
impacts that criminal behavior has on these groups and provide
programming that is socially and culturally appropriate for the offenders’
needs. Offenders requiring high-intensity programming are often less
motivated to participate. Therefore, to encourage their continued
participation more than one facilitator is used to better engage the
offender in the program. These programs also make use of one-on-one
counselling, in addition to highly structured group work, as a method of
maintaining the motivation of the offenders.
4. Offender characteristics are matched to staff; including personal
characteristics (gender, age, life experiences, training) and relationship styles
(empathy, fairness, firmness, spontaneity).

Through training, program facilitators are encouraged to show empathy and

understanding of the offenders’ challenges while at the same time remaining
firm on the program objectives and avoiding the reinforcement of antisocial
attitudes. In the case of Aboriginal programs, Aboriginal people are used as
facilitators to better match offenders and facilitators in terms of cultural
backgrounds.

5. Positive reinforces outnumber punishers by a ratio of 4:1. Training sessions

demonstrate how to deliver positive reinforces during group sessions to
encourage both positive change in behavior and participation in the program
activities.
6. Intervention periods of three to nine months are used since shorter periods
do not provide sufficient time for relationships to develop and there is need for
time in the treatment setting to practice the interventions learned.

High intensity programs last three to four months, or longer, to provide

sufficient time for the offender to integrate the ideas that are discussed. For
moderate and low intensity programs the duration is less than recommended
here, but this is overcome by the use of maintenance programs that are
delivered after the completion of the main program. The maintenance
programs may be delivered in the institution or in the community to reinforce
the concepts learned in the program and to further encourage the offender to
make the changes needed to address their needs.
 
7. Program staff are adequately trained with an understanding of the theory
behind the intervention; they are provided with time to become experienced
and familiar with the program content before delivering it; and smaller
programs (number of locations where the programs are being delivered) are
often observed to be more effective.

8. Assessment and evaluation of the program is on-going and integral to the

program so changes in behavior and attitudes can be measured, skill
development can be assessed and program outcomes can be demonstrated.

Prior to the start of most programs an assessment battery, consisting of a

structured interview, questionnaires and standardized assessment tools are
completed. During the program and at its end, these assessment tools are
completed again to determine if there have been changes in the offenders’
knowledge, attitudes, beliefs etc.
Results of these assessments are used first by the facilitators to ensure that the
program is achieving its objectives. These assessment results are also
accumulated and used in research, with additional data on release outcome, to
determine if the program is effective in changing recidivism and improving the
release options of offenders.
EXAMPLES OF TREATMENT APPROACHES
Four treatment approaches will be presented in this section, stages of change,
relapse prevention, motivational interviewing and harm reduction.

A. Stages of Change
Model of readiness to change that allows treatment providers to match
treatment to an individual’s willingness to change. In their model, they propose
five stages of change and provide examples of what should be addressed at each
stage and what is required for the person to move to the next stage. These
stages are meant to be representative of what happens and individuals will not
pass through the stages as if they were discrete events.
(i) Pre-contemplation
In the pre-contemplation phase an individual has no intent to change his or her
behavior and the behavior may be viewed as being both positive and negative for
the individual. During this phase it is not useful to focus on changing behavior,
but rather to use motivational techniques that will move the person to the next
phase. The person may need to acknowledge that there is a problem, develop a
better understanding of the negative consequences of the behavior, and develop
an understanding of the factors that trigger it. An individual at this stage may
believe they are in control and can stop anytime and believe that the benefits of
using outweigh the benefits of not using.
(ii) Contemplation
In the contemplation stage the individual is thinking about their problem and is
looking for information that will help them to understand it. They are looking at
the positive and negative characteristics of the behavior, but they are not yet
prepared to stop it. Intervention at this stage involves providing increased
understanding of the effects of the behavior, evaluation of life goals and
consideration of the context in which the person may be living. In the case of
offenders, if they are incarcerated it is a good opportunity to point out the
negative impacts that being in prison have on their life and what the
alternatives might be.

At this stage, the person must make a decision to act if they are to move to the
next stage. They might begin to take some preliminary action such as meeting
with a counsellor, changing their behavior, or reducing the risks associated with
it.
(iii) Preparation
The third stage is preparation for change. Persons in this stage are prepared to
change both their attitudes and their behavior. They may have taken some early
steps to monitor their behavior with the goal of reducing the frequency of it.
They are ready to be encouraged to participate in treatment so intervention
should work to increase their commitment to stopping the behavior.

This can be done by further development of information on the consequences

of the behavior and the positive benefits they may experience by reducing it or
stopping completely.

At this stage individual will need to establish goals and priorities that can be set
to help them stop the negative behavior. They will need to develop a change
plan that can guide their efforts to change.
(iv) Action
In the action stage individuals have begun to change their behavior. They are
learning new skills that help them to remain free from the negative behavior.
Their desire to change at this stage makes them ideal candidates for programs
that apply behavior change practices in treatment. Treatment needs to provide
skills development that will assist in the cessation of the behavior while
providing alternatives to their former lifestyle. Participants also need to learn
about what may trigger their negative behavior so that they can avoid these
situations.
(v) Maintenance
The final stage in this model is maintenance, the process by which the individual
maintains his or her desired behavior. This is a critical phase as it is the one that must
last for the remainder of a person’s life if they are to avoid resuming their former ways.
They must have in place practices that will allow them to avoid substance abuse and
continue to practice the skills learned in treatment. Very often, treatment programs do
not provide for maintenance support. Rather, the program is delivered, the person
successfully completes it and then is expected to maintain the change without any
additional support.
Effective programs have maintenance components that provide support and
skills reinforcement during the maintenance stage. An individual does not
move through these stages in a straight line. They may move from pre-
contemplation to preparation, only to slip back to the contemplation stage.
Or, they move all the way to maintenance, but as a result of life
circumstances, may find themselves starting the process again. This is both
expected and normal and is one of the reasons that effective programs
stress the need for understanding of lapses in drug and alcohol use during
and after treatment.
B. Relapse Prevention
Relapse prevention should be an important component of treatment programs.
As noted earlier, relapse is a common occurrence and the individual needs to be
prepared for it when it occurs. The goals of relapse prevention are to provide
information useful in recognizing high risk situations that may lead to relapse and
providing the skills needed to deal with the relapse when it does occur. At the
time of a relapse, it is important that the client does not give up.

C. Motivational Interviewing
Many offenders are not willing to commit to changing their negative behavior.
There are too many positive features associated with their lifestyle. They are in
the pre-contemplative stage of change. However, treatment providers must work
to encourage these individuals to move forward along the continuum towards
change. Motivational interviewing is one of the methods that have been shown
to be effective for starting the change process.
(i) Express empathy
For motivational interviewing to be effective the counsellor must express
empathy with the client. The client is accepted for what he or she is at the time
of counselling, there is no judgment about how they arrived at that point, or
the consequences of their behavior. Accepting the individuals as they are
reducing their resistance to the counselling setting. Ambivalence about change
is acceptable for the client.

(ii) Develop discrepancy

Developing discrepancy has to do with gently demonstrating the conflicting
values in a person's life and guiding them towards the more appropriate goals.
This is different from confrontation that may result in resistance to change.
While discussing the current situation with the client the counsellor looks for
positive personal goals that the individual has and contrasts these with the
current behaviors that prevent the achievement of these goals.
The object is to encourage the client to see the importance of the alternative
goals they have and to give this greater priority than the desire to use drugs
and alcohol.

(iii) Avoid argumentation

The counsellor needs to avoid argumentation to maintain a positive
therapeutic relationship with the client. However, this does not mean that the
therapeutic interview follows the clients’ thoughts. Rather, inconsistencies are
detected and used to correct judgments and beliefs.

They also note that in many treatment settings argumentation can occur
around the need to admit to having a problem. This is unnecessary at this early
stage of change, and may only be recognized as a goal much later. Recall that
the purpose of motivational interviewing is to prepare the client for change, to
move them along the continuum so they are ready to start the change process,
or in some cases after a relapse, to restart the process.
(iv) Roll with resistance
It is to be expected that the offender will be resistant to change, and it is the job of
the counsellor in motivational interviewing to work with this resistance to find ways
to reframe and redirect the resistance. Redirecting the resistance can motivate
offenders to find their own solutions, which is the ultimate goal of the program.

(v) Support self-efficacy

The offender will often feel that they are unable to succeed in treatment so it is
pointless for them to try. Motivational interviewing helps the offender to believe
that they can change; it works with their desire to change and develops confidence
that change is possible. The counsellor may encourage small steps towards change
to assist the offender to build on success. Motivational interviewing is often used as
an adjunct to other therapies. An offender who is in the pre-contemplative or even
the contemplative stage of change is not ready for a directive behavioral program.
Motivational interviewing can move them along so they better understand the
need for change, see the value it may provide for them, and provide the belief
that they have the ability to maintain the behavior if they desire. A parole officer
reviewing the results of objective testing can provide the offender with concrete
evidence of how his or her behavior compares to that of other offenders.

The report produced by the Correctional Service of Canada's Computerized

Assessment of Substance Abuse (CASA) is designed to be shared with the
offender for this reason. It is our intention, in the near future, to include
normative data in the report, so offenders can see how their problem compares
to that of other people. This approach should help to address problems of denial
that are common among drug and alcohol abusers.
D. Harm Reduction
Harm reduction is a concept that grew from awareness of the deadly
consequences of injection drug use following the appearance of HIV/AIDS.
Through the very common practice of sharing syringes and other drug
paraphernalia it became possible for an individual to suddenly have an
incurable, fatal disease. People working with drug abusers recognized the need
to take some action that would lessen the probability of the spread of disease
without passing judgment on the drug using behavior.
Harm reduction is more than a number of specific interventions. It is an
approach to intervention that seeks to reduce the negative consequences of
substance abuse to the individual and to the society. Rather than looking at drug
or alcohol misuse as an inherently bad thing, harm reduction takes no position
on the acceptability of the behavior. However, it recognizes that substance abuse
has negative effects and therefore actions can be taken to reduce those harms.
Simply reducing the harms may help to stabilize the behavior of individuals,
assist in keeping them alive, and reduce the negative consequence for the
community in which the substance-abusing individual lives.

Harm reduction is not a treatment program, but an intervention. However, one

of the values of harm reduction is that it can provide opportunities for further
intervention with addicted individuals that may lead to their participation in
more traditional programming, thereby leading to a reduction in their use of
drugs and alcohol, and in many cases to their total abstinence from drug and
alcohol use, if that is warranted.
(i) Harm reduction is a public health alternative to the moral, criminal and
disease models of drug use and addiction.

Harm reduction does not presume that substance abuse is morally wrong and
must therefore be punished using criminal sanctions, nor does it take the view
that substance abuse is a disease that requires treatment. However, given the
negative consequences of substance abuse, encouraging people to stop using is a
goal as indicated in the next principle.

(ii) Harm reduction recognizes abstinence as an ideal outcome, but accepts

alternatives that reduce harm. Harm reduction can be viewed as having a
continuum of responses. At one end of the continuum is the cessation of all
substance-abusing behaviors, thereby eliminating all of the harm associated with
substance abuse. At the other end of the continuum is any small reduction in the
harms caused by substance abuse.
Frequently, harm reduction becomes associated with only the most
controversial options such as safe injection sites. While safe injection sites are at
the leading edge of harm reduction, they are not the place to start developing a
harm reduction policy. Correctional systems can take a harm reduction
approach by ensuring that its policies and procedures go as far as they can to
reduce the harms associated with substance abuse.

(iii) Harm reduction has emerged primarily as a ‘bottom up’ approach based on
addict advocacy, rather than a ‘top-down’ policy promoted by drug policy
makers. As a result of how the harm reduction approach was developed, it is
well accepted and meets the needs of people who require intervention.
(iv) Harm reduction promotes low-threshold access to services as an alternative
to traditional, high-threshold approaches. Traditionally, many programs
required a commitment to total abstinence before a person could be accepted
into treatment. If there was drug or alcohol use during the program the person
was removed from treatment. These types of strict rules set a high threshold
for participation. Programs that have low-threshold access have very few rules
for initiating and participating in the intervention. Effective needle exchange
programs do not require anything of the substance abuser other than collecting
clean syringes.

It is easy to imagine a needle exchange program that required participation in

treatment, completion of forms, etc. to obtain clean needles. Experience has
shown that any of these requirements reduces the effectiveness of needle
exchange.
Another example of a low threshold program is a methadone treatment
program offered in Halifax, Canada, in which there are a minimum number of
requirements for participation, unlike most methadone programs. Individuals in
this program must obtain their methadone each day, and must undergo
urinalysis to check for the presence of other drugs. The presence of other drugs
results in counselling, and cessation of methadone only occurs if the level of
use of other drugs is seen as a threat to health.

(v) Harm reduction is based on the tenets of compassionate pragmatism versus

moralistic idealism. Making condoms available in correctional settings is one
example of compassionate pragmatism. We recognize that sexual activities will
occur in prison, we want to prevent the spread of diseases, and providing
condoms does not provide any security risk, therefore they are made available.
Some prisons have incorporated therapeutic communities (TCs) modified for the special
needs of offenders, and a growing number of community TC programs are providing
aftercare for people released from prison. TCs for offenders differ from other TCs in
several ways. As with all offenders, inmates participating in a TC must work during their
incarceration. However, they also spend 4 to 5 hours each weekday in treatment, with
an emphasis placed on living honestly, developing self-reliance, learning to manage
their strong emotions (e.g., anger), and accepting responsibility for their actions.

The CBT elements of treatment concentrate on developing the participant’s insight into
how his or her perception (or perhaps misinterpretation) of events affects emotions and
thoughts that justify criminal behavior. Ideally, therapeutic facilities are separate from
the rest of the prison so participants in treatment can live together in a community
based on mutual help. Treatment staff members, who include ex-offenders, act as role
models and lead social learning activities. In-prison TCs emphasize role models to show
"right living" and use peer influence to reinforce changes in attitudes and behavior.
Treatment also commonly addresses discharge planning to provide participants
with the information they need to access community services upon release for
finding housing, training, and treatment and generally facilitate re-entry into the
community. The best outcomes are seen when inmates participate in
community-based TC treatment during the transition from incarceration to
community re-entry and continue care after discharge to prevent relapse and
return to social connections and environments formerly linked to drug abuse and
crime.
9 Treatment Issues Specific to Prisons
The unique characteristics of prisons have important implications for treating
clients in this setting. Though by no means exhaustive, this chapter highlights
the most salient issues affecting the delivery of effective treatment to a variety
of populations within the prison system. It describes the prison population as of
2003, reviews the treatment services available and key issues affecting
treatment in this setting, and considers the question, “what treatment services
can reasonably be provided in the prison setting?”

The prison therapeutic community (TC) model is explored in depth and

examples of in-prison TCs are described. The chapter also looks at the treatment
options available for certain specific populations and at systems issues that
affect all clients in prison settings. The chapter concludes with some general
recommendations for substance abuse treatment in prisons.
Prisons differ from jails in that inmates generally are serving longer periods of
time (1 year or longer) and the offenders have often committed serious or
repeated crimes. Prisons and jails both vary in size, but prisons are unique in that
they are separated by function and inmate classification. Types of prisons
include:

Intake facilities (processing centers for inmates receiving orientation, medical

examinations, and psychological assessment) Community facilities (halfway
houses, work farms, prerelease centers, transitional living facilities, low-security
programs for nonviolent inmates)
Minimum security prisons (dormitory style housing for inmates classified as
the lowest risk levels serving relatively short sentences for nonviolent crimes)

Medium security prisons (higher security risks such as those with a history of
violence) 

Maximum security prisons (most restrictive prisons for violent inmates and
those posing the highest security risks)
Multi-use prisons (inmates of different security classifications generally used in
States with smaller prison populations)
Specialty prisons (for inmates with special needs, such as people with mental
illness, physical disabilities, or HIV/AIDS) (National Center on Addiction and
Substance Abuse [CASA] 1998).
At the end of 2003, State and Federal prisons in the United States housed a total
of 1,470,045 inmates. This meant that there were approximately 482 sentenced
inmates for every 100,000 United States residents. About 1 in every 109 men
and 1 out of every 1,613 women were incarcerated by State or Federal
authorities.

Employing both male and female counselors is helpful in an all-male program, as

male inmates may be less guarded and confrontational with female staff.
Treatment staff also should focus on gender dynamics that affect many male
participants' willingness to assess honestly their own conduct, typically including
behaviors such as avoiding responsibility, excessively blaming others, and
repressing feelings.
For many incarcerated men, learning to express anger in healthy and
constructive ways is vital. Many male offenders have been perpetrators of
domestic and/or sexual violence and/or have gotten into trouble because of
fighting or assaults. Violence prevention groups may help participants explore
thoughts, feelings, and behaviors that are often the underpinnings of violent
behavior and sexual aggression—issues such as a lack of empathy, narcissism,
anger management problems, an overblown sense of entitlement, and the lack
of effective thinking skills and sense of self-efficacy.

Research shows that sexual offenders may be at greater risk for violent assaults
by other offenders (Brady 1993). By taking a “scattershot” approach that treats
all participants as if they have a history of violence or sexual offenses, rather
than singling out specific individuals, treatment providers can address latent
and manifest coercive behavior focusing attention on specific individuals.
Women's Intensive Treatment Program
National Institute on Drug Abuse (NIDA)-sponsored research indicates that three
frequent treatable problem areas in women's lives are substance abuse,
recurring criminal behavior, and personality disorder. The Women's Intensive
Treatment Program at the Maryland Correctional Institution—Women (MCI-W)
was initiated to address these problem areas and to provide more intensive
treatment alternatives (Richards et al. 2003).

The 9-month residential program is composed of individualized treatment

planning, focused treatment modules, and work or school. It is geared toward
offenders with 3 years remaining to serve, whose psychopathy is not too severe
for the program, and who, after screening, are considered able to benefit from
treatment. Modules include anger management, moral problem solving,
addiction awareness, relapse prevention, early memories, trauma recovery,
social skills, and empowerment.
Six key treatment principles guide the treatment process:
• Clear focus on public safety, which guides all treatment decisions and effective
teamwork with other MCI-W departments

• Attunement to the particular needs of female inmates (e.g., unique pathways

to crime, trauma histories) is critical

• Assessment-driven treatment planning, which avoids a “one-size-fits-all”

approach in favor of individualized planning
• Dual diagnosis programming for the approximately 70 percent of women with
mental illness

• A minimum stay of 6 months

• The use of motivational enhancement techniques

• Women may create intimate relationships and family groupings to meet their
relational and emotional needs. It is important that in-prison treatment
programs work with female participants to help create healthy prosocial
relationships to meet these needs. Female inmates can draw the strength to
change in a new peer group, rather than feel pressure from their old peer
group to conform by engaging in drug-taking or criminal behavior. Additionally,
a strong core of female staff provides opportunities for role modeling and for
developing healthy non-coercive relationships with inmate participants.
Treatment Components
In-prison treatment incorporates several different models, approaches, and
philosophies for the treatment of substance use disorders, as described in the
following section.

Counseling
In its prison study, CASA found that 65 percent of prisons provide substance
abuse counseling. Of those, 98 percent offered group counseling and 84 percent
offered individual counseling. Nearly one-quarter (24 percent) of State inmates
and 16 percent of Federal inmates participated in group counseling while
incarcerated (CASA 1998).
Group counseling
As the most common treatment method, group counseling seeks to address the
underlying psychological and behavioral problems that contribute to substance
abuse by promoting self-awareness and behavioral change through interactions
with peers (CASA 1998). Although the intensity and duration of group therapy
can vary, trained professionals typically lead groups of 8 to 10 inmates several
times a week with the expectation that participants will commit to and engage
in meaningful change in an emotionally safe environment. Group sessions
typically range from 1 to 2 hours in length.
Cognitive-behavioral groups
Substance abuse treatment programs in correctional settings should be organized according
to empirically supported approaches (i.e., those based on social learning, cognitive-behavioral
models, skills training, and family systems). Programs based on nondirective approaches or
medical models or those focusing on punishment or deterrence have not been shown to be
effective. Cognitive programs include such strategies as “problem solving, negotiation, skills
training, interpersonal skills training, rational-emotive therapy (REBT), role-playing and
modeling, or cognitively mediated behavior modification”.

Cognitive/behavioral/social learning models emphasize interventions that assist the offender

in changing criminal beliefs and values. Such interventions concentrate on the effects of
thoughts and emotions on behaviors, and include strategies (e.g., behavioral contracting) that
promote prosocial behavior and accountability through a system of incentives and sanctions.
Examples of cognitive-behavioral group interventions include the National Institute of
Corrections' Thinking for a Change curricula (online at
www.nicic.org/pubs/2001/016672.htm), the Criminal Conduct and Substance Abuse
Treatment.
Specialty groups
Specialized treatment groups are often organized around a shared life
experience (e.g., children of alcoholics, incest survivors, people with AIDS) or
common problem (anger management, parenting, stress reduction, or
prerelease planning). Specialty groups offer a chance to work on specific issues
that may be impeding other treatment initiatives or require special attention not
readily available in the regular program.
Two types of specialty groups are briefly described below.

Anger management groups. Anger management groups are widely used in drug
treatment programs. They are especially helpful for inmates who are either
passive and nonassertive or express anger in an explosive fashion. By careful
analysis of emotional reactions to painful and threatening experiences,
treatment staff help the inmate learn to manage anger in a more socially
acceptable manner. For example, inmates may feel incapable of expressing
negative feelings verbally. Instead of responding appropriately to a provocation,
they allow feelings to build up, which leads to a delayed explosive reaction.
Learning to express angry feelings verbally and in an appropriate manner helps
inmates feel more competent about interpersonal relationships.
Parenting groups. Very successful groups have been organized around
parenting issues. Although the perspective may differ for females and males,
bonds to children can help motivate the recovery process for both genders and
can contribute to a successful re-entry into the community. Practitioners have
found that both men and women need to focus on developing parenting skills
and overcoming patterns of neglect, abandonment, and abuse. As a result of
parenting work, some program participants have tried to find their children and
establish relationships with them upon release to the community. The process
of becoming a responsible parent can be a critical component in the recovery
process.
Family counseling
Family therapy is a systems approach that often focuses on large family
networks. Family and friends can play critical roles in motivating individuals with
drug problems to enter and stay in treatment. When possible, involvement of a
family member in an individual's treatment program can help prepare the
individual for parole. Often caution needs to be exercised when involving
families of offenders because of high degrees of antisocial behavior and
psychological disturbance. For more information on using family therapy in
substance abuse treatment see TIP 39, Substance Abuse Treatment and Family
Therapy (CSAT 2004).
Individual counseling
Individual counseling is an important part of substance abuse treatment.
Counselors may operate from many different philosophical and theoretical
orientations and employ a variety of therapeutic approaches in individual therapy.
The common feature of such sessions is that inmates in a private consultation are
free to explore more sensitive issues, which they might not be ready to discuss in
a group. Individual sessions also provide a place where a counselor can coach
inmates on relapse prevention techniques such as how to recognize specific high-
risk situations, personal cues, and other warning signs of relapse.

Like group counseling, individual therapy strives to help offenders develop and
maintain an enhanced self-image and accept personal responsibility (CASA 1998).
It can act as an important adjunct to group therapy. Additionally, skilled
psychologists and social workers who offer individual therapy to offenders play a
role in the development and review of a client's treatment plan.
Self-help groups
Self-help groups, found in a majority of State and Federal prisons, are frequently
a crucial component of recovery and can provide a great deal of support to
recovering offenders. Self-help groups provide peer support and may serve as
therapeutic bridges from incarceration to the community.

Self-help programs were founded by individuals who found conventional help

inadequate or unavailable. These individuals shared common problems and a
personal commitment to do something about their condition. Self-help
programs are not considered “services,” which require client dependence on
providers. Instead, they are programs based on a philosophy of self-
responsibility. The philosophy involves a powerful belief system that requires
individuals to commit to their own healing. For many, this approach has proven
inspiring and successful.
A major focus of the self-help approach is altering the fundamental beliefs
and overall lifestyles of participants. By taking responsibility for their own
problems, individuals can gain control over their situation and develop a
new sense of self-respect and competence. Recovering role models provide
support and guidance. The entire approach can result in far-reaching
changes in personal lifestyles and social relationships. In general, the self-
help movement successfully instills the more positive aspects of
individualism—self-reliance and responsibility—while also stressing the
importance of group effort in overcoming common problems.
The concept of empowerment is perhaps the most central to understand the
positive effects of self-help groups. (For other benefits, see below.) Self-help
processes are geared to invoke and develop a sense of personal power among
members. Empowerment can be derived from a “higher power,” from the
group, or entirely from within the individual, where the idea of “bottom line”
responsibility for the conditions of one's life teaches members that they have
the power to alter their lives and living conditions. Self-help groups also
encourage members to use their personal strength to enable others to feel less
helpless. This, in turn, enhances the power of the helper. Since self-help
programs are peer centered, they encourage mutual support and offer many
opportunities for leadership.
The Benefits of Self-Help Groups
• Support for substance abuse treatment and recovery
• Peer support
• Healthy peer interaction
• Therapeutic bridges between the criminal justice system and the community
• Crisis prevention and management
• Personal growth
The best known self-help groups are Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA). However, other self-help groups may be appropriate,
depending on the offender's beliefs, needs, and interests. Other groups
include Survivors of Incest Anonymous, Secular Organizations for Sobriety
(SOS), religious groups, women's groups, and veteran support groups.

One survey found that 74 percent of prison facilities offered self-help

programs of various types. Of those, AA had the strongest representation (in
95 percent of those facilities), followed by NA (in 85 percent). Less than one
third offered other types of self-help programs. Because of the lack of
empirical evidence about the effectiveness of self-help programs in reducing
recidivism and relapse, the consensus panel believes that these groups are
best viewed as support activities that can enhance more structured and
intense treatment interventions (CASA 1998).
At times compulsory self-help group attendance is used as a sanction. The
panel feels that the compulsory use of any treatment or supportive service as a
sanction is ill advised and can be detrimental to other treatment efforts.
Moreover, the constitutionality of mandatory participation in spiritual-based
groups has been challenged. When compulsory attendance is a part of the
treatment, secular alternatives should be made available.
Educational and vocational training
Educational and vocational training, in addition to attention to psychosocial and
behavioral needs, is a critical dimension that helps offenders become
responsible family members, employees, and community members. The
acquisition of skills such as basic literacy, GED certification, and life skills can
improve employment opportunities and improve self-esteem.

Such enhancements also can help keep inmates from returning to substance-
using subcultures and ways of life. These services are generally provided by the
prison and must be closely coordinated and monitored by the treatment staff as
part of case management function.
Advice to the Counselor: Prison Treatment Approaches
• Treatment in prison environments should be organized according to
empirically supported approaches, such as social learning, cognitive-
behavioral models, skills training, and family systems.

• Nondirective approaches, some medical models, and those focusing on

punishment or deterrence have not been shown to be effective.
Therapeutic Techniques
Specific therapeutic techniques can be especially helpful in treating the prison
population. As discussed below, role-playing and video feedback can help offenders
improve awareness of how others experience and perceive their behavior. Other
models that have received increased attention include motivational interviewing,
faith-based initiatives, token economy models, and the resurgence of a more
traditional medical-pharmacological model that includes the development of
medications to remove the organic effects of cocaine (i.e., craving-based treatment
interventions).

Typically, therapeutic techniques are not used as stand-alone interventions but

rather blended into a treatment approach or model that addresses multiple needs
with multiple techniques. Also, evaluation studies usually test the efficacy of program
models such as the TC and rarely test the effectiveness of individual treatment
techniques. However, the following interventions have been widely used in
correctional treatment and have gained clinical validity among many practitioners.
Role playing
Role playing exercises have been used with incarcerated populations since the
1950s, particularly in residential treatment settings. These exercises take
advantage of the fact that inmates are experienced at playing roles negatively
and direct that skill toward a positive end. Prior to participation in guided role
playing, inmates learn the rules and purpose of this technique. This approach
has been particularly effective with perpetrators of violence, as these individuals
often remove themselves emotionally from their victims. Using role play,
inmates often take turns acting as both victims and perpetrators.
Destructive behavior patterns, frequently rooted in childhood, can be evoked
and re-experienced. This process helps the individual understand old patterns to
avoid repeating them. Roles can also be reversed so that perpetrators
experience the emotions and thoughts of their victims. Habitual offenders
typically feel remorse not for the crime committed but for being caught.
Experience of appropriate guilt and desires to make restitution for their crimes
are major goals of role playing exercises.
Video feedback
Video feedback can be a valuable therapeutic tool in correctional rehabilitation.
Video feedback allows inmates to “see themselves as others see them.” For
example, viewing a tape of their intake interview helps inmates cut through
denial as a result of witnessing their own body postures, gestures, and facial
expressions. Video sessions can also help inmates identify different behavior
patterns, attitudes, and self-images. Inmates who have spent their lives on the
streets may change their self-perception by seeing themselves in a video,
perhaps dressed in a suit, speaking and behaving differently than before.
Watching tapes of group sessions and of other activities, inmates can begin
to view themselves differently. This is especially valuable for those with poor
self-images. Inmates may have no access to visual images of themselves,
since full-length mirrors are not typically available in jail or prisons. Lacking
important information for forming an accurate self-image, an inmate's
problem may be less a matter of poor self-image than of no self-image. In
such cases, videotapes can play an important role in treatment.
“Blended” approaches
The “blended model” recognizes that a melding of different approaches and
techniques can prove effective in prison-based treatment. More subtly, the
corrections environment itself already incorporates a blended approach, simply
because the nature of prisons requires adaptation of existing structural and
security concerns.

Blended approaches expand in-prison treatment offerings to include more

innovative techniques and treatment modalities. These require creativity, the
imaginative use of available resources, proper identification of inmate problem
severity (i.e., the more severe the inmate's problem, the more intensive the
treatment services), support for programming, adequate physical plant and
design, attention to the impact of activities on classification and movement,
cost, monitoring, and continued professional development of correctional staff.
One example of a blended approach program is the Residential Substance Abuse
Treatment located at the South Idaho Correctional Institution. It offers a
combination of three treatment strategies, including cognitive-behavioral and
12-Step programming set within a TC (Stohr et al. 2001). A unique feature is its
target population: parole violators who abuse substances. Using qualitative and
quantitative data collection techniques, an initial evaluation team determined it
to be sound in content and service delivery.
Components
The TC's daily regimen involves the resident in a variety of work, educational,
therapeutic, recreational, and community activities. Main program components
are.

• Community meetings, events, and ceremonies

• Seminars
• Group encounters
• Group therapy
• Individual counseling (both from staff and peers)
• Tutorial learning sessions
• Remedial and formal education classes
• Client job-work responsibilities
Explicit treatment phases that are designed to provide incremental degrees of
psychological and social learning TCs differ from self-help groups, such as AA, in
that they are structured, hierarchical, and highly intense intervention programs
while AA provides peer support only.

The TC treatment experience promotes a sense of camaraderie, safety, and

communication as keys to transformation from degradation to dignity. One of the
most complex treatment models to implement and operate in a prison, TCs
require significant changes in the norms, values, and culture of the environment
and a great deal of commitment and cooperation from prison administration and
staff to properly structure and control that environment.
While residents must take responsibility for their own recovery process,
treatment staff, including ex-offenders, act as role models and provide
support and guidance. Individual counseling, encounter groups, peer
pressure, role models, and a system of incentives and sanctions form the
core of treatment interventions in a TC. Residents of the community must
live together, participate in groups, and study together. In the process,
inmates learn to control their behavior, become more honest with
themselves and others, and develop self-reliance and responsibility.
TCs are most often implemented in a residential structure isolated from the
general population to provide enough safety and sense of belonging to begin
the process of change. States of anxiety, secrecy, fear, and alienation—
conditions permeating the antisocial inmate subculture of the general prison
population—are antithetical to positive change. In fact, separation from the
prison subculture during treatment has been found to be most conducive to
achieving major changes in attitudes and behavior. However, the safe TC
environment, coupled with gains in interpersonal skills, helps offenders relate to
the general prison population with the inner strength needed to combat the
negative cues of the prison environment.
Practitioners note that there can be no “watchers” in a TC, only active
participants. TCs demand the participation of the inmates in the emotional,
physical, and intellectual work required for the process of change and
personal growth. Work in a TC, as a part of treatment, involves an increasing
set of responsibilities designed to build self-confidence and coping skills. As
active participants in their own recovery process, inmates learn self-
sufficiency and competence. Practitioners often cite an old maxim that
captures the essence of the TC philosophy: “Give people a fish and they have
food for a day. Teach them to fish and they can obtain food for a lifetime.”
TCs depend on the staff and participants' community-building capabilities.
The degree and intensity of confrontation with participants tends to
correspond to the strength of the supportive atmosphere of the program.
Confrontation in prison, for example, may be less intense than in a
community-based environment, since confrontation can be a threat to
prisoner codes of acceptable behavior. The success of the TC also depends
on the collaboration between treatment and corrections staff in
classification of inmates who are appropriately assessed and placed in
treatment as well as in the delivery of sanctions and removal from the
treatment unit.
Program Elements of a TC
Rod Mullen, founder of the Amity prison TC program, has attempted to
define the program elements needed for a TC and suggests that programs
that do not meet this standard be identified simply as “residential” to avoid
indiscriminate use of the TC identification:
• Twenty-five to 50 percent of the staff should have a substance abuse
history and at least 2 years of continual sobriety.

• The program must emphasize peer leadership and a structure of peer

responsibilities and authority.

• The program must have a defined structure of community ceremonies that

occur daily (as well as at other intervals), which reinforce the beliefs and
mission of the community.
• Regular encounter groups are held for all participants and confidentiality of
the group is a paramount community value.

• All staff members participate in community activities.

• The emphasis of the community is on the healthy, positive development of all

aspects of its members.
Successful Prison-Based TC Programs
The TC is widely recognized as an effective approach that is highly intensive
in nature and scope, deals effectively with issues related to implementation
and maintenance, and addresses many of the more important treatment
issues. Some examples of successful in-prison TC programs are described
below along with references that provide further information.
Stay'n Out in New York
The Stay'n Out program was implemented in July 1977 as a modified
hierarchical TC. Stay'n Out began at a time when many other in-prison TC
programs were closing. Program capacity was 120 inmates at the time this
research was conducted. Residents lived in two housing units segregated from
the rest of the prison population. They had contact with prisoners in the general
population only when off the TC unit (e.g., at the cafeteria, infirmary, library).
The Stay'n Out staff comprised mostly persons in recovery with TC experience.
Delaware KEY-CREST programs
The KEY-CREST programs, evaluated by the Center for Drug and Alcohol Studies
at the University of Delaware, represent a treatment continuum that mirrors the
offenders' custody status (Inciardi et al. 1997). Prisoners with a history of drug-
related problems are identified and referred to the KEY TC program. Following
prison release, parolees then go to the CREST program, a TC-based work-release
program. Six-month post-release relapse and recidivism rates for graduates of
both KEY and CREST were significantly lower than for program dropouts and a
non-treatment comparison group.
Amity prison TC
Originally established as a demonstration project funded by the California
Department of Corrections in 1989, the Amity TC is located at R.J. Donovan
Correctional Facility in San Diego, a medium security prison.

The program uses a three-phase treatment process. The initial phase (2 to 3

months) includes orientation, clinical assessment of resident needs and problem
areas, and planning interventions and treatment goals. Most residents are
assigned to prison industry jobs and given limited responsibility for the
maintenance of the TC. During the second phase of treatment (5 to 6 months),
residents are provided opportunities to earn positions of increased
responsibility by showing greater involvement in the program and by focusing
on emotional issues.
Encounter groups and counseling sessions address self-discipline, self-worth, self-
awareness, respect for authority, and acceptance of guidance for problem areas.
During the reentry phase (1 to 3 months), residents strengthen their planning and
decision-making skills and work with program and parole staff to prepare for their
return to the community.

Upon release from prison, graduates of the Amity prison TC may elect to participate
in a community-based TC treatment program for up to 1 year. Residents at this
Amity Aftercare TC have responsibility for maintaining this facility (under staff
supervision) and continuing the program curriculum. The aftercare TC also provides
services for the wives and children of residents.

An evaluation conducted by the Center for Therapeutic Research at the National

Development and Research Institutes, Inc., assessed 36-month recidivism outcomes
for a prison TC program with aftercare using an intent-to-treat design with random
assignment.
Texas Kyle New Vision Program
The Kyle New Vision program was the first in-prison TC (ITC) developed under
1991 State legislation that outlined plans for several corrections-based
substance abuse treatment facilities in Texas. It is a 500-bed facility that
provides treatment to inmates during their final 9 months in prison. After
release, parolees are mandated to attend 3 months of residential aftercare in a
transitional TC (TTC), followed by up to another year of supervised outpatient
aftercare. An evaluation conducted by the Institute for Behavioral Research at
Texas Christian University revealed that 3 percent of those who completed both
ITC and TTC programs were rearrested within 6 months of their release from
prison, compared to 15 percent of those who only completed the ITC and 16
percent of an untreated comparison group.
Furthermore, results from hair specimens collected during a 6-month
followup indicated that fewer of those who completed both the ITC and TTC
tested positive for cocaine (the primary drug of choice for those in the
sample), compared to those who completed only the ITC and a comparison
group. A recently completed study showed that TTC completion following
the ITC was the strongest predictor of remaining arrest-free for 2 years
following release from prison. Aftercare completion was strongly associated
with parolee success. A 3-year outcome study revealed that high-severity
aftercare completers recidivated only half as often as those in the aftercare
dropout and comparison groups. These results indicate that intensive
treatment can be effective when it is integrated with aftercare and that the
benefits of intensive treatment are most apparent for offenders with more
serious crime and drug-related problems.
Federal Bureau of Prisons
While not technically a TC program, the Federal Bureau of Prisons offers
voluntary residential treatment programs, or Drug Abuse Programs (DAPs), for
alcohol and drug problems that use some of the features of the TC model.
Inmates participate in a total of 500 hours of treatment over a 9-month period
and programs have 1 staff member for every 24 inmates. Program goals are to
identify, confront, and alter the attitudes, values, and thinking patterns that led
to criminal behavior and substance abuse.

This is accomplished through a unit-based approach (whereby program

participants are segregated from the general population to build a treatment
community), and also through standardized program content that includes 450
hours of programming using modules devoted to a variety of subject areas.
Though initially implemented without incentives, the passage of time saw the
introduction of financial achievement awards; consideration for a full 6 months in
a halfway house for successful DAP program completion; and tangible benefits
such as shirts, caps, and pens with program logos. The passage of the Violent
Crime Control and Law Enforcement Act of 1994 allowed eligible inmates with
successful completion rates to reduce as much as a year from their statutory
release dates.

The second component is graduate maintenance, an 8-week program for those

who completed the initial component. Skills are reinforced from the first
component and transition plans are initiated. The third and final component,
aftercare, provides services from completion of graduate maintenance to release
from department custody. This component attempts to reinforce attitudinal and
behavioral changes that occurred during the first three phases. Transition plans
are regularly reviewed, placements for inmates in community-based programs
are completed, and tracking occurs for all inmates at regular intervals.
Use of “Lifers” as Peer Counselors at Amity
In 1990, the Amity prison TC at the R.J. Donovan Correctional Facility, a medium
security facility, began to accept offenders who were under life sentences (i.e.,
“lifers”) as counselors in its substance abuse treatment program. It remains one
of a handful of programs in the country to do so.

• Lifers were accepted as members of the counseling staff because they could
provide stability to the program and ensure its continuity. They are available to
program participants 24 hours a day, unlike staff from outside the prison, and
can have a vital role in keeping a community alive and helping to hold its
members responsible for their behavior. Because these are individuals who have
considerable respect in the prison community, they are able to help keep
participants in the program safe and out of situations that can cause them
trouble.
• The program is selective about who can become a counselor; all counselors
have to be graduates of the program and then complete a 2-year internship.
They must be individuals who have the respect of their peers and demonstrate
high levels of motivation. The program also ensures that this group represents
the racial demographics of the prison population.

• Programs that are considering using lifers should already have trained staff
who are experienced working with this particular subpopulation. The culture of
lifers is unique within the prison system, and the problems they face are also
often different. These are individuals whose home, for much (if not all) of the
rest of their lives is the prison. Becoming a counselor enables lifers to make
personal restitution for past acts by helping others, which they may never have
the opportunity to do so outside the prison environment. During follow-up
interviews, many of the successful program participants mentioned that lifers
had been important influences in their recovery.
CORRECTION AND REHABILITATION OF PENITENT OFFENDERS

To effect the rehabilitation and reintegration of probationers, parolees,

pardonees, and first-time minor drug offenders as productive, law-abiding and
socially responsible members of the community through well-planned
supervision programs for probationers, parolees, pardonees, and first-time
minor drug offenders which are aligned to national program thrusts of the
government, such as, the Sariling-Sikap, Jail Decongestion, etc. establishment
of innovative and financially and technically feasible projects for the moral,
spiritual and economic upliftment of probationers, parolees, pardonees, and
first-time minor drug offenders utilizing available community resources.
All offenders granted probation, parole, pardon and suspended sentence. The
Administration has adopted a harmonized and integrated treatment program for
these clients to affect their rehabilitation. This harmonized and integrated
program involves (1) The Therapeutic Community Modality (2) The Restorative
Justice Principles and Concepts and (3) the Use of Volunteer Probation Aides
(VPAs).

The Therapeutic Community Modality is a self-help social learning treatment

model used for clients with problems of drug abuse and other behavioral
problems such as alcoholism, stealing, and other anti-social tendencies. As a
treatment model, it includes four (4) categories, namely, behavior management,
intellectual/spiritual aspect, emotional and social aspects, and
vocational/survival aspects.
In this regard, the Therapeutic Community Modality provides a well-defined
structure for a synchronized and focused implementation of the various
intervention strategies/activities undertaken by the Agency such as:

1. Individual and group counseling 

This activity intends to assist the clients in trying to sort out their problems,
identify solutions, reconcile conflicts and help resolve them. This could be done
either by individual or group interaction with the officers of the Agency.

2. Moral, Spiritual, Values Formation 

Seminars, lectures or trainings offered or arranged by the Agency comprise these
rehabilitation activities. Active NGOs, schools, civic and religious organizations are
tapped to facilitate the activities.
3. Work or Job Placement/Referral
Categorized as an informal program wherein a client is referred for work or job
placement through the officer’s own personal effort, contact or information.

4. Vocational/Livelihood and Skills Training 

The program includes the setting up of seminars and skills training classes like
food preservation and processing, candle making, novelty items and handicrafts
making, etc., to help the clients earn extra income. Likewise, vocational and
technical trade classes are availed of such as refrigeration, automotive mechanic,
radio/television and electronics repairs, tailoring, dressmaking, basic computer
training, etc. through coordination with local barangays, parish centers, schools
and civic organizations.
5. Health, Mental and Medical Services
To address some of the basic needs of clients and their families, medical
missions are organized to provide various forms of medical and health
services including physical examination and treatment, free medicines and
vitamins, dental examination and treatment, drug dependency test and
laboratory examination.

Psychological testing and evaluation as well as psychiatric treatment are

likewise provided for by the Agency’s Clinical Services Division and if not
possible by reason of distance, referrals are made to other government
accredited institutions.
6. Literacy and Education
In coordination with LGU programs, adult education classes are availed of
to help clients learn basic writing, reading and arithmetic. Likewise, literacy
teach-ins during any sessions conducted for clients become part of the
module. This is particularly intended for clients who are “no read, no write”
to help them become functionally literate.

Likewise, linkages with educational Foundation, other GOs and NGOs are
regularly done for free school supplies, bags and uniform for client’s
children and relatives.
7. Community Service
This program refers to the services in the community rendered by clients for the
benefit of society. It includes tree planting, beautification drives, cleaning and
greening of surroundings, maintenance of public parks and places, garbage
collection, blood donation and similar socio-civic activities.

8. Client Self-Help Organization

This program takes the form of cooperatives and client associations wherein the
clients form cooperatives and associations as an economic group to venture on
small-scale projects. Similarly, client associations serve another purpose by
providing some structure to the lives of clients where they re-learn the basics of
working within a group with hierarchy, authority and responsibility much like in
the bigger society.
9. Payment of Civil Liability
The payment of civil liability or indemnification to victims of offenders are
pursued despite the economic status of clients. Payment of obligations to the
victims instills in the minds of the clients their responsibility and the
consequences of the harm they inflicted to others.

10. Environment and Ecology 

To instill awareness and concern in preserving ecological balance and
environmental health, seminars/lectures are conducted wherein clients
participate. These seminars/lectures tackle anti-smoke belching campaign,
organic farming, waste management, segregation and disposal and proper care
of the environment.
11. Sports and Physical Fitness
Activities that provide physical exertion like sports, games and group play are
conducted to enhance the physical well-being of clients. Friendly competition of
clients from the various offices of the sectors, together with the officers,
provide an enjoyable and healthful respite.

The success of the Therapeutic Community treatment model is also anchored

on the implementation of restorative justice. To highlight the principles of
restorative justice, offenders are recognized to indemnify victims and render
community services to facilitate the healing of the broken relationship caused
by offending the concerned parties. Mediation and conferencing are also
utilized in special cases to mend and/or restore clients’ relationship with their
victim and the community.
Considering that it is in the community that the rehabilitation of clients takes
place, the utilization of therapeutic community treatment model coupled with
the principles of restorative justice would be further energized with the
recruitment, training and deployment of Volunteer Probation Aides (VPAs). The
VPA program is a strategy to generate maximum participation of the citizens in
the community-based program of probation and parole. Through the VPAs, the
substance of restorative justice is pursued with deeper meaning since the VPAs
are residents of the same community where the clients they supervise reside.
Thus, it is practicable for the volunteers to solicit support for clients’ needs and
assist the field officers in supervising the probationers, parolees, and pardonees.
The Therapeutic Community treatment modality, Restorative Justice paradigm and
deployment of VPAs integrated into one rehabilitation program have yielded
tremendous outcome in the rehabilitation and reformation of probationers,
parolees, pardonees, and first-time minor drug offenders.

Furthermore, the Agency believes that the client’s family is a major part or
support in the rehabilitation process, thus the Administration adopts the
Integrated Allied Social Services program to address the needs of the children and
other minor dependent of the clients. Under the said program, interventions
relative to the growth and development of the minor dependents are done to
help them become productive, law abiding and effective individuals.
REFERENCES
• BARTOLLAS, C. (1981) Introduction to corrections. New York: Harper & Row
Publishers.
• BERNE, E. (1972) Games people play: the psychology of human relationships.
Ringwood:
• Harmondsworth: Penguin Books.
• BRACKE, R. (1996) De encounter, het hart van de therapeutische gemeenschap [The
• encounter, the heart of the therapeutic community]. In De Nieuwe Therapeutische
• Gemeenschap (eds E. Broekaert, R. Backe, D. Calle, A. Cogo, G. van der Straeten &
• H. Bradt). Leuven: Garant.
• BRATTER, T.E., COLLABOLLETTA, E.A., FOSSBENDER, A.J., PENNACHIA, M. &
• RUBEL, J. (1985) The American self-help residential therapeutic community. In
• Alcoholism and Substance Abuse. Strategies for Clinical Intervention (eds T.E.
• Bratter & G.G. Forrest). New York: The Free Press.