The Therapeutic Community Approach:
Essential Elements and Adaptations for Special Populations and
Settings.
GEORGE DE LEON Ph.D.
Center for Therapeutic Community Research @ NDRI
Clinical Professor of Psychiatry; NYU School of Medicine
Presented at
FADAA/FCCMH ANNUAL CONFERENCE
AUG 7-9, 2013, ORLANDO, FLORIDA
The TC: A Recovery Oriented Approach
 Emerged from the Substance Abusers
themselves.
 TCs serve the most serious substance abusers;
Severity of Substance abuse, psychological
dysfunction and social deviancy).
 TCs address the disorder of the whole person
and focus on recovery goals: changes in lifestyle
and identities.
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The Therapeutic Community Perspective
Four Interrelated Views
View of Disorder 
Drug abuse is a disorder of the whole person involving some
or all the areas of functioning.
• Cognitive, behavioral, emotional, medical, social and
spiritual problems
• Physical dependency must be seen within the context
of the individual’s psychological status and life style
• Problem is the person, not the drug
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The Therapeutic Community Perspective
View of the Person 
Rather than drug use patterns, individuals are
distinguished along dimensions of psychological
dysfunction and social deficits.
Some shared characteristics:
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Poor tolerance for frustration, discomfort, delay of gratification
Low self-esteem
Problems with authority
Problems with responsibility
Poor impulse control
Unrealistic
Difficulty coping with feelings
Dishonesty, manipulation, self-deception
Guilt (self, others, community)
Deficits (reading, writing, attention, communication)
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The Therapeutic Community Perspective
View of Recovery 
The goals of treatment are global changes in lifestyle and
identity.
Some assumptions about recovery:
• Recovery is developmental learning
• Self-help and mutual self-help
• Motivation
• Social learning
• Treatment is an episode in the recovery process
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The Therapeutic Community Perspective
View of Right Living 
Certain precepts, beliefs and values as essential to self-help
recovery,, personal growth and healthy living.
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Some examples:
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Truth/Honesty (in Words and in Actions)
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Here and Now (Living in the present)
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Personal Responsibility for their recovery and life style
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Social Responsibility ("Brother's/Sister's Keeper")
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Work ethic (Economic self reliance, standards of excellence)
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Moral Code Concerning Right and Wrong Behavior
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Inner Person is "Good", but Behavior Can be "Bad"
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The TC Approach: Community As Method

The purposive use of community to
teach individuals to use the community
to change themselves.
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Community as Method
Four interrelated components
 Community is the context of peer and staff
relationships, and the daily regimen of activities.
 Community sets the expectations for individual’s
participation.
 Community assesses the individual’s progress in
meeting these expectations.
 Community responds to individual’s meeting
expectations.
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Community, the individual and the Process
of Change
 Individuals use the context and expectations of the
community to learn and change.
 Meeting community expectations requires continual self
change in behaviors, attitudes and emotional management.
 Avoidance of, or difficulties in, meeting community
expectations also results in individual growth through
continual self examination, re-motivation to engage in the
trial and error learning and re-commitment to the change
process.
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Community, the individual and the Process
of Change
 Thus, in striving to meet community expectations for
participation residents pursue their individual goals of
socialization and psychological growth.
 This process is summarized in the phrase: if you
participate, then you will change.
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Components of a Generic TC Program
***
•Community separateness
•A community environment
•Community activities
•Staff roles and functions
•Peers as role models
•A structured day
•Work as therapy and education
•Phase format
•TC concepts
•Peer encounter groups
•Awareness training
•Emotional growth training
•Planned duration of treatment
•Continuity of care
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TC: SPECIAL POPULATIONS
TC APPROACH AND MODEL HAS
BEEN ADAPTED AND MODIFIED FOR VARIOUS
POPULATIONS.
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Variants of TCs
The extent to which the program is guided by TC perspective
and approach (Communty as Method)
 Standard TCs: Guided by perspective and method but may
incorporate other evidence informed practices to enhance
community as method.)
 Modified TCs: Guided by TC perspective and method but
adapted for special populations and settings. Incorporates
special services ( eg., mental health, medicational, other health
services).
 TC Oriented; Not guided by TC perspective or community as
method.Uses selected elements of the TC (eg. a community
meeting, peer support group etc) but mainly services and
practices not specific to the TC.
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Current Modifications
of the TC Model
 Treatment
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Twelve-step components
Mental health services
Other Evidence Based Practices (CBT, MET, RPT, DBT)
Contingency contracting
Pharmacotherapy
Family Therapies
 Social and Health Services
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Family services approaches
Primary health care and medical services
Aftercare services
Vocational, Educational, Housing
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Current Applications for Special Populations
and Settings
Special Populations
• Adolescents, Juvenile Justice clients
• Addicted mothers and children
• Incarcerated substance abusers
• Mentally ill chemical abusers
• AIDS- and HIV-seropositive clients
• Elderly substance abusers
• Methadone maintained clients
Special Settings
• Prisons, jails, Community Correctional facilities
• Hospitals, day treatment clinics, methadone clinics
• Homeless Shelters, Halfway Houses, Alternative schools
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General Summary of Modifications of TC
Practices and Program Elements for Special Populations and Settings
 The treatment goals, planned duration of treatment, flexibility of
the program structure and in the intensity of peer interactions all
accommodate individual differences.
 Successful implementation of TC program models within special
settings requires accommodation to the goals, procedures,
personnel, general practices, and restrictions of these settings.
 Special services and interventions are integrated into the program
as supplemental to the primary TC treatment (Community as
method).
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General Guidelines of Adaptations of the TC
 Adhere to the perspective on recovery and right living and
to the fundamental approach—community as method.
 Retain basic components of the generic model including its
social organization, work structure, daily schedule of
meetings, groups, seminars and recreational activities and
program phases.
 Integrate the variety of staff conceptually in the TC
perspective and approach through intensive and
continuous cross training.
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TC : An Evidence Based Approach
The main findings and conclusions are summarized
from multiple sources of research: Field outcome
studies, controlled/comparison studies, meta-analytic
surveys, cost benefit analyses and indirect evidence
from outside of TCs
Evidence:
Field Effectiveness Studies
Main Conclusions
 Who comes for treatment? Profiles of Admissions are the
most severe.
 What are the success rates? Individuals change during and
following treatment.
 Does Treatment “Dosage” relate to Outcomes? Retention
consistently predicts outcomes.
Retention and Outcomes
Success rates in a therapeutic community by months in treatment
100
90
80
Percent
70
60
1970-71 Cohort
2 Cumulative years
post-treatment
50
40
30
1974 Cohort
2 Cumulative years
post-treatment
20
10
0
N=18
N=10
N=23
N=32
N=16
N=35
N=33
<1
1-4
5-8
9-12
13-16
17+
Grad.
N=13
N=10
N=14
N=13
N=11
N=30
N=16
BEHAVIORAL AND PSYCHOLOGICAL OUTCOMES: 5
YEARS AFTER TC TREATMENT
MALE OPIATE ADDICTS: DROPOUTS (N=110)
Modified TCs for Special Populations
Main Findings and Conclusions
 Provide a positive cost benefit compared to traditional
approaches in correctional settings, mental health facilities,
shelters.
 Improvements occur on both behavioral (drug use,
criminality and employment) and mental health status (eg.,
symptoms, re-hospitalization, adherence to medications,
health care).
 Sources: TIPS 42, 44, De Leon, 2008
Indirect Evidence
Evidence Based Principles within TCs
 Although TCs emerged outside of mainstream
social science and mental health, familiar social
psychological principles are evident.
 Evidence based learning principles in TCs:
• social role training,
• vicarious learning,
• behavior modification
 These are naturalistically mediated through
Community as method.
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Indirect Evidence
(TC practices and elements supported by research outside
the TC)
 Peer mentoring; Peer Role modeling, tutoring
 CBT, RPT,TC concepts: Topics in Peer/staff Seminars
 “Therapeutic Alliance”: The individual’s relationship with
the community rather than with a specific therapist:
 Motivational enhancement: Group process focus on
problem identification and desire to change: Role Models
who illustrate motivation in attitude and behaviors.
 Goal Attainment: The TC Program Stages and Phases
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TC is an Evidenced Based Treatment
 “Weight” of the research evidence from all sources
supports the conclusion that the TC is an effective and cost
effective treatment for certain subgroups of substance
abusers, particularly those with severe drug use, social and
psychological problems.
 Evidenced based social psychological principles and
practices are embedded within Community as method.
(Indirect Evidence)
 Other Evidenced informed strategies can be incorporated
to enhance, not substitute for, community as method, the
primary approach.
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Suggested References
Books, Chapters, Articles
• De Leon, G. (2000). The Therapeutic Community: Theory, Model, and
Method. New York: Springer Publishing Company. New York
(English, Spanish, Portuguese, Norwegian, Polish)
• De Leon, G. (Ed.). (1997). Community as Method: Therapeutic Communities
for special populations and special settings. Westport, CT: Greenwood
Publishing Group, Inc. Now ABC-CLIO LLC. Santa Barbara. Ca.
• De Leon, G. (2008). Therapeutic communities. In M. Galanter, & H.D. Kleber
(Eds.), The American Psychiatric Publishing textbook of substance abuse
(4th Edition, pp. 459-476). Washington, DC: American Psychiatric Publishing,
Inc.
• De Leon, G.(2010) Is the Therapeutic Community an Evidenced Based
Treatment? What the Evidence Says. International Journal of Therapeutic
Communities 31, 2, summer 104-128
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Suggested References
Videos (De Leon)
• Stages of Recovery (2005). Center for Criminality and
Addictions Research (CCARTA) University of California,
San Diego UCSD
• The Therapeutic Community:(2005) Volume 1 The
Therapeutic Community Perspective; The Therapeutic
Community Training Series. Amity Foundation
Psychotherapy.net.
• The Therapeutic Community:(2005) Volume 2. Community
as Method; The Therapeutic Community Training Series.
Amity Foundation. Psychotherapy.net
• The Therapeutic Community:(2005) Volume 3 Components
of a Generic Therapeutic Community.The Therapeutic
Community Training Series. Amity
Foundation.Psychotherapy.net
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