THERAPEUTIC COMMUNITY CURRICULUM Trainer’s Manual

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THERAPEUTIC COMMUNITYCURRICULUMTrainer’s ManualU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment1 Choke Cherry RoadRockville, MD 20857

AcknowledgmentsNumerous people and organizations contributed to the development of this curriculum (see appendices Cand D). The curriculum was prepared for the Substance Abuse and Mental Health ServicesAdministration (SAMHSA) by JBS International, Inc. (JBS), under Knowledge Application Program (KAP)contract numbers 270-99-7072 and 270-04-7049 with SAMHSA, U.S. Department of Health and HumanServices (DHHS). Christina Currier served as the Center for Substance Abuse Treatment (CSAT)Government Project Officer, and Andrea Kopstein, Ph.D., M.P.H., served as the Deputy GovernmentProject Officer. Lynne MacArthur, M.A., A.M.L.S., served as JBS KAP Executive Project Co-Director, andBarbara Fink, R.N., M.P.H., served as JBS KAP Managing Project Co-Director. Other KAP personnelincluded Dennis Burke, M.S., M.A., Deputy Director for Product Development; Candace Baker, M.S.W.,Senior Writer/Publication Manager; Wendy Caron, Editorial Quality Assurance Manager; FrancesNebesky, M.A., Quality Control Editor; Leah Bogdan, Junior Editor; and Pamela Frazier, DocumentProduction Specialist. Sandra Lundahl, M.P.H., served as Lead Training and Curriculum Designer withAFYA, Inc., under a subcontract to JBS.The Therapeutic Community: Theory, Model, and Method, by George De Leon, Ph.D., was used as aprimary source for this curriculum with the permission of Springer Publishing Company, Inc., New York,NY. Dr. De Leon provided consistent support for this project.DisclaimerThe opinions expressed herein do not necessarily reflect the official position of CSAT, SAMHSA, orDHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or forparticular instruments, software, or resources described in this document is intended or should beinferred.Public Domain NoticeAll material appearing in this publication except that taken directly from copyrighted sources is in thepublic domain and may be reproduced or copied without permission from SAMHSA. Do not reproduce ordistribute this publication for a fee without specific, written authorization from the Office ofCommunications, SAMHSA, DHHS.Electronic Access and Copies of PublicationThis publication may be accessed electronically through the following Internet address:www.kap.samhsa.gov. For additional free copies of this curriculum, please call SAMHSA’s NationalClearinghouse for Alcohol and Drug Information (NCADI) at (800) 729-6686 or (800) 487-4889 (TDD).Recommended CitationCenter for Substance Abuse Treatment. Therapeutic Community Curriculum: Trainer’s Manual. DHHSPublication No. (SMA) 06-4121. Rockville, MD: Substance Abuse and Mental Health ServicesAdministration, 2006.Originating OfficePractice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment,Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD20857.DHHS Publication No. (SMA) 06-4121Printed 2006

ContentsTrainer Orientation. 1Introduction.1The TCC Learning Approach .3Using the Trainer’s Manual .4Overview of the Participant’s Manual .7Getting Started. 9ModulesModule 1: Introduction to the Therapeutic Community Curriculum. 1-1Module 2: The History and Evolution of the Therapeutic Community. 2-1Module 3: Treatment and Recovery—The TC View . 3-1Module 4: The Community-as-Method Approach . 4-1Module 5: The TC Social Structure and Physical Environment . 5-1Module 6: Peer Interpersonal Relationships . 6-1Module 7: Staff Roles and Rational Authority . 7-1Module 8: TC Treatment Methods . 8-1Module 9: Work as Therapy and Education . 9-1Module 10: Stages of the TC Program and the Phases of Treatment . 10-1Module 11: How Residents Change in a TC . 11-1AppendicesAppendix A: Ice Breakers. A-1Appendix B: Positive Visualizations .B-1Appendix C: TCC Expert Panel. C-1Appendix D: TCC Contributors . D-1iii

Participant OrientationIntroductionBackgroundLeaders in the therapeutic community (TC) model of treatment have identified a critical need forentry- level staff training in the basics of the TC model. 1 In response, the Substance Abuse andMental Health Services Administration’s Center for Substance Abuse Treatment (CSAT)convened an expert panel in 2000 to serve as a planning committee for a generic TC curriculum(TCC) and to provide guidance during its development (see appendix A for a list of expert panelmembers and appendix B for a list of other contributors). This document is the result of thatcollaboration.TCs have evolved to serve an ever- increasing range of special populations with substance usedisorders, including women with children, older adults, adolescents, people with co-occurringmental disorders, people with HIV/AIDS, people who are homeless, and people involved withthe criminal justice system. In addition, the TC approach has been passed down rather informallythrough succeeding generations of TC program staff, allowing a shift away from the foundationsof the TC model2 and necessitating a concrete and standardized method of training both clinicaland nonclinical staff.In an interview with Therapeutic Communities of America News, the Director of CSAT, H.Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, advised that, as the TC model continues toevolve, TC practitioners and administrators should stay anchored to the essential premises ofTCs so that changes are based on “your [TC practitioners’] own information, your owntraditions, your own histories so you don’t get fads . . . [but] progressions that are logical,sustained, and meaningful.” 3The TCC was developed to facilitate such logical and meaningful evolution of the TC model byproviding TC staff members with an understanding of the essential components and methods ofthe TC and helping them understand and appreciate that they are part of a long tradition ofcommunity as a method of treatment.LanguageIn presenting generic TC concepts and methods, TCC developers use terms that are acceptedwidely in TCs. In some cases, several alternative terms (provided by TCC reviewers) areincluded. You may find that your TC uses terms that differ from those used in the TCC.Although the number of outpatient programs using the TC model is increasing, most TCprograms remain residential. For this reason, developers use the word “resident” throughout thedocument rather than TC “participant,” “member,” or “client.”PM 1

PARTICIPANT’S MANUALTCC Goals and ObjectivesGoals: To provide a common knowledge base for all staff members working in TCsTo encourage you to work on your professional growth and development.Objectives: As you progress through the TCC training, you will Understand and be able to explain–––––– The history, basic concepts, and components of the TCThe TC views of the disorder, the person, recovery, and right livingThe social structure and physical environment of the TCThe TC treatment methodsThe ways in which staff members help residents change their behavior, attitudes, andself- identity through the community-as- method and the self- help and mutual self- helplearning processesThe expectations, roles, and competencies of all staff membersExperience increased self-awarenessBe able to identify concerns about your roles and the ways to obtain additional information,support, or trainingExperience and understand the TC process through participation in simulations and roleplays of TC methodsExperience an enhanced sense of belonging to a TC.The TCC Learning ApproachThe 11 modules in the TCC can be delivered over several consecutive days or can be offeredover the course of several weeks or months. Each module also can be used separately to target aspecific training need. Your trainer will provide you with a specific agenda.The TCC learning approach includes PM 2A mixture of presentations, discussions, and exercises to simulate the self- help and mutualself-help learning processes used in TCs.Frequent use of a static small- group exercise format.Simulations and role plays to understand better the TC method.Time to reflect on and write your thoughts and feelings in a personal journal. This journalis yours to keep; your trainer will not collect it, and you will not be expected to share whatyou have written unless you choose to do so.An assessment of your learning to be completed in your small groups at the end of eachsession.A wrapup exercise to help make the transition home or back to work on a positive note.Brief “prework” assignments to prepare for the next session.

PARTICIPANT ORIENTATIONThe TCC is not an immersion approach but can complement your agency’s immersion training.You will find that the TCC is highly interactive but that it is more didactic than the immersiontrainings you may have experienced. The developers have tried to balance presentations andexercises, and your trainer will allow you to take breaks as needed.Experiential exercises and group simulations can trigger emotional responses. Your trainer willprovide basic support and guidance appropriate to a training situation as issues arise during thetraining but will not be able to provide individual counseling. If you feel that you need moresupport, you can Talk to a coworker, friend, or family memberTalk to a sponsor or therapistRequest referral to your program’s employee assistance program.The TCC is an entry-level training to familiarize new staff members with basic TC principlesand methods. It does not take the place of immersion or other clinical skills training or ongoingclinical supervision.Overview of the Participant’s ManualEach module of your Participant’s Manual includes PowerPoint slides printed three to a page with space for you to write notesResource Sheets containing additional information, case studies, and exercisesA summary of the main points of each moduleA learning assessment to complete with your small group (the module review).Your trainer will give you a notebook to use as your personal journal.Getting the Most From Your Training ExperienceHere are suggestions to get the most from the TC training:qqqqqqqSpeak to your supervisor before the training begins. Find out what his or her expectationsare for you.Think about what you want to learn from each module.Come to each session prepared, do any prework that was assigned, and review thesummaries for the modules to be presented.Be an active participant. Participate in the exercises, ask questions, write in your journal,and think about what additional information you want.Speak to your supervisor after the training. Talk to him or her about what you learned to besure you understand how the information relates to your job.Discuss with your supervisor ways that you can put your learning into practice, andcontinue to follow up with him or her.Have fun!PM 3

PARTICIPANT’S MANUAL123De Leon, G. Therapeutic Communities: Theory, Model and Method. New York: Springer Publishing Company,Inc., 2000. Chapter 1, page 6.De Leon, G. Therapeutic Communities: Theory, Model and Method. New York: Springer Publishing Company,Inc., 2000. Chapter 1, page 6.Therapeutic communities and high functioning: An interview with Dr. H. Westley Clark, Director of the Center forSubstance Abuse Treatment. Therapeutic Communities of America News, Spring/Summer 1999.PM 4

Module 1: Introduction to the Therapeutic CommunityCurriculumPreparation Checklistq Review Getting Started (page 9) for preparation information.q Review Module 1, including Resource Sheets, Summary of Module 1, and Review ofModule 1.q Prepare an appropriate icebreaker (see appendix A for suggestions).q Decide on the jobs participants will perform during the training. Prepare newsprint of astructure board for Therapeutic Community Curriculum (TCC) training. (See the SampleStructure Board at the end of Module 1.) Depending on the number of participants, someparticipants may have more than one job, or a participant may share a job with anotherperson. Participant jobs may be changed daily. Job assignments are optional but mayenhance the development and cohesiveness of the training community.q Write on newsprint the following ground rules for the training (modify as needed), and postthem on the wall: Arrive on time, and return on time from breaks.Participate in all assigned activities.Consider one another equal members of the training community.Do not smoke in the building.Do not bring food to the tables; beverages are permitted.Turn off cell phones, and set pagers to vibrate during training.q In addition to the materials listed in Getting Started, assemble the following for Module 1: A packet of 11- by 17- inch colored construction paper OR poster board for small groups Crayons or magic markers for small groups.1-1

TRAINER’S MANUALModule 1 Goals and ObjectivesGoals: To develop a training community; to provide participants with an overview of the TCC’sgoals and objectives, structure, and learning approach; to introduce participants to theTherapeutic Communities of America (TCA) Staff Competencies; and to introduce participantsto one TCA Staff Competency: “acting as if.”Objectives: Participants who complete Module 1 will be able to Explain the overall goal and the objectives of the TCCState at least five TCA Staff CompetenciesDefine the concept “acting as if” and describe at least one way staff members candemonstrate this concept in their work with TC residents.Content and TimelineIntroductionPresentation: Overview of the TCCExercise: Small- Group FormationBreakPresentation: TCA Staff CompetenciesPresentation: TCA Staff Competency—Understanding andPracticing the Concept of “Acting as If”Summary and ReviewJournal Writing and WrapupTotal Time1-230 minutes30 minutes45 minutes15 minutes20 minutes10 minutes20 minutes20 minutes3 hours, 10 minutes

MODULE 1TCC MODULE 1Introduction30 minutesWelcomeWelcome participants, introduce yourself, and summarize your experience in TCs.OH #1-1Distribute and review the agenda.Conduct an icebreaker, and process as needed.Ask participants to introduce themselves by their names and their work affiliations(if the icebreaker did not accomplish this).Review the list of posted ground rules.Invite participants to add rules to the list.Explain that Affirmations are oral encouragements offered spontaneously by peers toacknowledge one another and their efforts to change.Affirmations are expressed with affection, friendship, and caring.Encourage participants to affirm one another throughout the training.Participant Job AssignmentsIntroduce participant job assignments posted on the TCC Structure Board.Explain that it is important for participants to have jobs during the training because Community members are expected to perform jobs to keep the communitygoing.Contributing to community work develops a sense of belonging.Each participant is responsible for enhancing the learning environment, whichin turn enhances the learning experience for participants.Having a job during the training simulates the TC learning environment.Explain that the role of work in the TC is discussed thoroughly in Module 9.Assign each participant a job to do today or throughout the training.1-3

TRAINER’S MANUALTCC MODULE 1Presentation: Overview of the TCC30 minutesOverviewExplain that the TCC provides A thorough introduction to general TC principles and practices for new TC staffmembers A solid review for more experienced staff members.Emphasize that The TCC is part of a comprehensive training program for TC staff members. Additional skills-based training and ongoing clinical supervision are essentialto staff member competence.Explain that The TCC training environment incorporates elements of the TC experience, butnot to the same extent as most immersion training. The TCC involves simulations and role plays to help participants understandthe TC method. Trainers provide basic support and guidance appropriate to a training situationif issues arise for a participant during the training but do not provide individualcounseling to participants.Encourage participants needing more than minimal support to Talk to a coworker, friend, or family memberTalk to a sponsor or therapistSeek out or request referral to the program’s employee assistance program.TCC Goals and ObjectivesDistribute the Participant’s Manual, and refer participants to page PM 1-6 toreview TCC goals and objectives.Review the overall goals and objectives of the TCC.Overall goals: To provide a common knowledge base for all staff membersworking in TCs and to encourage training participants to work on theirprofessional growth and development.1-4

MODULE 1TCC MODULE 1Overall objectives: Participants who complete the TCC will1. Understand and be able to explain The history, basic concepts, and components of the TCThe TC views of the disorder, the person, recovery, and right livingThe social structure and physical environment of the TCThe TC treatment methodsThe ways in which staff members help residents change their behavior,attitudes, and self- identity through the community-as-method and the selfhelp and mutual self- help learning processesThe expectations, roles, and competencies of all staff members2. Experience increased self-awareness3. Be able to identify concerns about their roles and ways to obtain additionalinformation, support, or training4. Experience and understand the TC process through participation in simulationsand role plays of TC methods5. Experience an enhanced sense of belonging to a TC.The TCC Learning ApproachExplain that the TCC learning approach includes A mixture of presentations, discussions, and exercisesSmall- group work to create a sense of community and to promote self- help andmutual self- helpTime to reflect and write thoughts and feelings in a personal journalReview and feedback.Emphasize that The TCC learning approach includes exercises and processes to simulate thecommunity-as-method approach and the self- help and mutual self- help learningprocesses used in the TC. Each session begins with a review of the previous session, so participants canprovide

Therapeutic Community Curriculum: Trainer’s Manual. DHHS Publication No. (SMA) 06-4121. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006. Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment,