British and American Concept House Therapeutic Communities - 1967 to 1977

From TC Open Forum

Jump to: navigation, search

Some reflections of a decade of experience/s in British and/American Concept House Therapeutic Communities, 1967 to 1977" David Warren-Holland

by David Warren-Holland

David Warren-Holland is founder and director of training at GCT Ltd (Groupwork Consultation & Training). David received his groupwork training at the Phoenix Institute NY, and also Europe and Great Britain. This covered a variety of social group/therapeutic models. He was a pioneer in the drug rehabilitation field, and was responsible with others for the early growth and development of two therapeutic communities in this country. For the last sixteen years David has worked as a social groupwork tutor/trainer in the health services, education and local authority settings, the voluntary sector, and probation service.;


Brief Early History

In late 1967 I was a psychiatric charge nurse at St. James Hospital, Portsmouth. A radically thinking psychiatrist, Dr Ian Christie, asked me to help set up what was to be called the Alpha Unit. I was seconded from the main hospital to the 'The Pink Villa Huts'. These were two wooden buildings situated in the hospital grounds. This was the inauspicious start of Great Britain and Europe's first 'Concept'-based therapeutic community.

The aspects of the philosophy which defined what came to be referred to as the 'Concept’ were this:

"To provide total rehabilitation for an individual in an existential context by challenging and reinforcing that which is positive and normal; so that the ability exists to eventually overcome that which is distorted and sick in the personality. Addiction as a way of life is merely a symptom of much deeper psychological problems." [Warren-Holland, D.; Cropwood Conference Cambridge (1978) (revised politically correct version 2000)].

Dr Christie had visited Daytop Village in New York the year previously, and it was decided to send two staff for further training to see the model/s at first hand. I was privileged to be one of those staff. I was seconded to New York for observation and training on two occasions. The first was in November 1969, for two weeks. I went with a psychiatrist from the hospital, Dr Alison Stookes, who was working part-time at Alpha House. Besides Phoenix in New York we visited other drug rehabilitation houses, including Encounter Inc., a community-based programme. We wanted to see how these models could be adapted to work in Great Britain.

Secondly we saw an A.S.T.R.O. (Addiction Specialist Training Rehabilitation Operation) on Hart Island, which was set up by the Phoenix's own Staff Training Institute. We were invited to participate. This was the very first experiential staff training for ex-drug-misuser staff who were graduates of the programme. We took part in Trust games, Gestalt, and Psychodrama sessions.

The second time I was sent for a longer period of three months, from November 1970 to January 1971. I lived in two very different Phoenix House Therapeutic Communities. One, in Putnam Valley in the Peekskill Mountains, was a working farm. There some of the residents were very young people, from seven years upwards, who had been addicted to heroin. The other house was in West 85th St. in the Bronx in New York, which at that time was in a high drug-use area. The training consisted of the first-hand experience of starting at the bottom of the programme hierarchy as a resident and working my way up to staff level. I discovered first-hand how a new resident must feel - the isolation, loneliness, and disorientation; with the added difficulty of trying to understand a different language.

When I came back to England three other staff were seconded including Dr Ian Christie.



Cultural Translation

One of the main problems facing us as a staff group on our return was how to adapt what was seen as an effective American model to Great Britain, bearing in mind the cultural and legal differences. This development was fraught with frustration and difficulty in the first three years, and will be the subject of another paper. But eventually we succeeded in establishing a viable treatment programme.

The use of former residents working as staff members was popular in America, but seen as very radical here. Despite that, by the end of 1972 Alpha House Portsmouth not only had the first group of British ex-users to become graduates of the programme, but achieved another 'first' two years later in 1974 when a British ex-user graduate became Director.

Staff were vetted carefully, and it was important to employ individuals who had genuine commitment, and who were willing to learn and understand the 'Concept' model. The staff mix that worked the best was one of both 'professional' - those with a non-addictive past, but with special skills/training that would benefit the community -, and ex-user graduates of the programme. The latter would have had at least one year working outside the house in a non-therapy setting before being allowed to come back as staff members; although in the early days, through necessity, this rule was not always adhered to.

An old piece of 'Concept' philosophy was: - You have to be able to 'walk the walk ' as well as 'talk the talk'. This applied to staff and residents in American and British 'Concept' Houses.

Senior residents and staff members who had been through the concept house process would often be the toughest on any negativity by residents in the community. It was one of the ways of reinforcing their own motivation to stay clean. The contribution of the main core of senior residents with a commitment towards a positive ethos in any community must never be underestimated. It is this peer strength that holds the real power in the house. New residents should only be admitted in small numbers, so as to maintain this balance. Staff who ignore, or fail to recognise this, do so at their peril: the senior resident ethos must always be respected, listened to, and reinforced; it is the only way a house will stay a positive environment for change, and remain drug free.

Life can be unfair at times, and residents have to learn how to cope with unfairness, to be able to understand the feelings that arise when something hurtful or negative happens to them, and not run back to using drugs, alcohol, or any other chemical to avoid feeling emotional pain. Learning experiences were given with care, and a great deal of thought was given as to their consequences. Timing is crucial; otherwise staff are in danger of repeating a resident's failure syndrome rather the reverse.

An example of one such experience was a senior resident who had been given the position of kitchen manager, and had been doing well. He was demoted for no other reason than the need for him to cope with the feelings that such action brought about. This may seem harsh, but you have to bear in mind that it was happening in a supportive 24-hour environment, and the resident had access to staff, residents and groups, and would be helped to talk through the feelings that arose: The parallel in life being that you may be in a job that you excel in but may be fired for no reason other than the post becomes redundant, or the boss just doesn't like you.

As human beings we instinctively know if someone is being caring or not. The Concept model was often called 'a crash course in growing up' or a 'learning experience for life'. Both these terms fit in a simplistic way the core of what has been called a 'tough love' model. Like all things human they can be abused, and in the past the motivation of some of the staff handing out these 'learning experiences' was not always of the best or the highest. Most times this would be picked up on and highlighted in the weekly staff groups.

It is important to recognise the negative side of the human condition which exists in all of us, and to have adequate safeguards in place. This applies in any 'caring' setting. For emotional growth and learning to make sense and be internalised it is important that everything in the community has a parallel in life, and insight comes from that understanding. Meaningful change for all of us is a frightening business.

The key elements for of this type therapeutic community to work are:

- The individual be physically withdrawn from all drugs. No proper learning can take place while a person is still using.

- The concept of self help and responsibility.

The recognition that drug taking is a symptom of underlying problems, and that an individual's reliance on chemical substances prevents them reaching a solution to these problems. Self help is vitally important to this process. It is important that a recovering drug user be given ample opportunity to aid their own recovery by the recognition that he/she has the capacity to assume responsibility for their life. Sometimes this means that an individual - though wanting to -, is not hungry enough to re-gain self respect by giving up a self-destructive lifestyle

- No Physical Violence - this cannot be tolerated, and a resident who acts out in this way is not ready to be in a therapeutic community.

- Acceptance of diversity: That people have differing opinions and see different paths through life.

- Treating residents as helpless and incapable deprives them of the opportunity to change, and panders to a continuation of their manipulative and irresponsible behaviour.

- The first three months of a resident's stay enables them to concentrate on total involvement in the community. This initial dependency is encouraged. A new resident is given support from both staff and residents and thoroughly orientated on the house rules/concepts. There is a clear understanding that the new person will try to behave in a responsible fashion. (Act as if).



The Hierarchical Structure

House organisation is based on a highly structured hierarchy, creating the maximum number of responsible posts with constant pressure on residents to seek responsibility and to exercise it with self-awareness and concern for others.

If successful, promotion up the hierarchy is the reward; failure to change results in demotion down the hierarchy. This is the 'carrot and stick’ principle. The resulting group dynamic that is created enables each resident to feel free to express initially a superficial, and later a deeper concern for others, and because of this to become more aware of themselves and their environment. This aids development of personality insights, and lays the foundation towards meaningful change.

An example of a simple Hierarchical House Structure for 50 residents could be:

Staff /Level Director Deputy Director Deputy Director Staff/Resident/Level House Co-ordinator (Senior resident usually 9-12 months seniority) Resident /level Expeditors Expeditors The eyes & ears of the house) Feedback to co-ordinator any thing that is happening in the community) (4-6 months seniority) Department Head (House Maintenance) Department Head (Kitchen) (Usually 4-6 months residents) Department Head (Garden) Department Head (Education) Each department would have around 8-10 residents in it depending on the size of the community). This system enabled individuals not only to take specific responsibility for crucial areas, e.g. feeding the house members, but also the principles of managing others within their departments/teams

The house structure is a mirror of life in society. It creates the dynamics needed for learning and change. New residents are told that anyone can enter the community from the bottom, and work their way up to the top. They could even be Director one day.



Act as if

All residents, from admission, are expected to 'Act as if’. This is a very basic form of cognitive-behavioural role playing. Residents are expected to be respectful to one another and show care and concern to each other even if they do not really feel it. The theory being: It is possible to integrate into one's personality what is being acted, if it is done long enough. ‘Act as if’ was followed by 'Think as if’, 'Feel as if’, "BE" (Something we all continue to aspire to life-long!) Thus the only time a resident is not allowed to 'act as if' and show their true self is in groups and in one-to-one counselling.



Encounter groups/other groups

One of the most effective therapeutic methods, which is seen as central to the therapeutic process, is a form of groupwork called the 'encounter group' or, as it was known at Synanon in California, ‘the Game’ In this intense group experience resident/s are encouraged to express forcefully any feelings, frustrations and emotions they may have, and gradually, with the help of others, gain further awareness of self, becoming in the process more aware of their impact of self on others and the environment, the eventual aim being to begin to mature emotionally from any insights gained.

Entering this type of group for the first time can be a noisy and shocking one. Emotional defences are often broken down, and a group member is encouraged to accept an 'indictment' made against them. New members should not be put in one of these groups for some time. They attend simpler induction groups before introduction to this group.

There is, however, a session after the encounter group which is as important as the group itself. This is a 'patching up' time, where group participants are encouraged to continue to share with the others in twos and threes what had happened to them, and how they felt. A softer atmosphere is created, ended with food and soft drinks. The theory behind this encounter model of groupwork is that many feelings are repressed during the period of time that a user is taking drugs. Therefore, 'emotional growth/development' stopped at the point that they began serious drug use. For example, if a resident started their drug use at the age of 14 that person may be 23 or even 35 years old chronologically, but because of their drug use they retain the emotions and acting out behaviour of a 14 year old.

The way a resident sees the world was once described to me as looking through a piece of card with a small hole in the middle. The person sees only what they are able to perceive through that hole, and nothing else around it. In other words, the drive of drugs produced 'tunnel vision' - nobody or nothing else mattered.

Historically there have always been fewer women than men in therapeutic communities. Whether this is because the ethos is more male-orientated, or because women have tended towards the option of prostitution as well as crime, it is difficult to say. Special women-only groups are held, and nowdays there are special 'Family Houses' where both partners who have been addicted can be with their children. These will have relationship/parenting groups and one to counselling.

There is a ban on sexual relationships for residents first entering the community, the reason being that residents are there to learn about themselves and see each other as people, and need to become friends with themselves and others before starting on a sexual relationship.



The Slip Box/Indictments

This is a wooden box accessible to all, usually kept in the foyer of the house, beside which are slips of paper. A resident writes out an 'indictment'. This means putting the name of the person on the slip who they wish to 'indict'. An indictment can be about anything: An example might be where another resident or even a staff member had acted in what was perceived to be a negative or un-caring way towards the slip-writer, and had created angry or hurt feelings. This then becomes a written commitment to deal with the resulting bad feelings in the next encounter group. Prior to the thrice- weekly encounter groups the slips are sorted, so as to ensure the two people concerned are together in that group. This is also a way of testing out the reality of possibly imagined or displaced feelings and not avoiding them. Since the feelings could also be valid, there is potential for learning on both sides.



Learning Experiences

Some of the toughest methods used were called ‘learning experiences’. These were seen in England at that time as very radical. Doubts were expressed by many as to whether they would work in this country. Most of them did!

Prospect Bench

This was a chair or bench in the foyer of the house, where a new resident would sit whilst waiting entry to the house. It also had the function of being a quiet place where a resident could sit, if they wanted to leave or had a problem and could not wait for the encounter group and wanted to let people know. It sometimes had a disciplinary function - a resident who was acting out in a negative fashion could be told to sit on the bench.

Dishpan

This would only be given for a major breach of rules, for example leaving the house and using drugs. If the resident wanted to come back, they would be given Dishpan, which meant that they worked in the kitchen washing up for the whole community. This could be for 2-3 weeks. They also had to make a commitment to talk about their feelings in groups. The reason behind this was that it gave the resident concerned a chance to earn back self respect for themselves and in the eyes of the community by sticking to what was, after all, a hard and fairly unpleasant task.


Placards

These have always been regarded as controversial. The resident concerned wore a placard which stated on it a negative behaviour or aspect of self that they were consistently not dealing with. It could say 'I refuse to talk about myself Ask me why', or, more seriously, 'I keep thinking about leaving Ask me why'. The resident wearing the placard had a responsibility to talk about why they were wearing it, and other residents were told to ask the person why they were wearing it. A placard would be worn for varying periods, usually 2-3 days or a week.

An example of this was when I was an 'honorary' staff member during my stay at Phoenix House West 85th St. New York. I was sitting in an office with a one of the Phoenix staff when a resident came in bearing a tray with lunch for the staff on it. The tray was covered in rather an excessive amount of silver foil. It was pointed out by the staff member quite politely that it was wasteful to put so much foil over the food, and not to do it next time. The next day this same resident brought in the tray with as much foil as before on it. The staff member told the resident off in stronger terms, and again pointed out the wastefulness etc. When it happened a third time, the staff member did not say a word to the resident, but took all the foil off the tray and fashioned it into a large silver bow tie about two foot across and told the him that he had to wear it for the rest for the week. He did not forget again. By 'engrossing' the behaviour it became a valuable learning experience for him.

Verbal dressing downs.

These were derived from the 'talking to's' that are given out in the services. It consisted of talking, sometimes shouting at a resident, who is not allowed to answer back. It meant they had to listen. It was usually about some aspect of a resident's behaviour that needed to be corrected. The aim was to 'highlight' this negative behaviour and encourage acceptance of self-discipline as an essential requirement in the real world.

Head shaves

This is probably one of the most controversial learning experiences used. It would not work today, because fashions and attitudes have changed so much; but in the late 60s and early 70s it did work. It was only used in extreme circumstances – Again, for someone who had left, used drugs, and wanted to come back into the community.

The idea was two-fold

1) It gave a choice of giving up part of themselves, to show commitment;

2) It meant they would stop and think before leaving and possibly killing themselves (which some invariably did, thinking that they could inject the same dose as before). If looked at in that context, the end justified the means. In my experience it saved a number of lives.

It was sometimes said that a resident grew emotionally at the same rate as their hair! This learning experience, however, was never given to women; as an alternative, they wore a stocking cap. This practice was adopted as an alternative in Alpha House for both men and women at a later stage.



The Re-entry Phase

This is the final, most difficult and important stage of the programme, everything previously having been a preparation for this. It begins after about three to six months with short trips out of the house on one's own. For a resident who has been living in the protective 24 hour environment of the house, this is where whatever emotional growth has been made will be put to the test.

A crucial part of the process is peer support. Weekly re-entry groups are facilitated by a senior staff member. The emotional bond forged by a group of residents that have been through a programme together is unique. Re-entry residents who had previously been encouraged to replace their dependence on drugs with dependence on the community now face leaving and 'detoxifying' from it.

Something one must remember and worth mentioning here, which relates to success rates, is that the prognosis for every resident coming into the house is very low. So, any success could be seen as an achievement.

On a resident's journey towards emotional growth and development, it is important to recognise that many people and agencies play a part. It is not exclusive to the project concerned. I always disagreed with the idea promoted by the early Synanon Model and some of the American projects of the 'Concept' being ‘the only way’.

Two key areas need to be concentrated on: getting a job, and improving education. Some residents have not done either. Often a resident who had achieved considerable personal status in the community faced becoming 'a very small fish in a very large pond'.

The difficulties faced by a re-entry person are considerable, and often daunting. They included:-

1) Getting a job

2) Enrolling in educational courses

3) Making new 'straight' friends/relationships - it was not wise to go back to old haunts, which were almost certainly in the drug culture;

4) Establishing contact again with family;

5) Alcohol - this had the potential for problems - re-entry people would frequently develop a taste for this instead of drugs.

Some communities had their own education department, so some of this process would have already started at say the six month stage. There is sometimes initial house contact with potential employers; but nevertheless it still falls to a re-entry person to actually 'get' a job.

Some people can re-lapse at this point. There should always be an opportunity to come back into the community and start again.


Conclusions

The ten year period written about in this paper covers a radical and exciting period of development for all of us who were involved at that time in the field of 'concept house' rehabilitation of drug-misusers.

Personally, apart from involvement in the early development of Alpha House already mentioned, I became from 1973 -77 Director of Phoenix House London. This period was the start of another developmental phase in my growth, which was linked to the further growth of the 'Concept' house movement as it had become. There were house 'jamborees' between the residents and staff of four of the houses that existed then in England, Alpha, Phoenix, Ley Community, and Suffolk House. At the same time I was invited to give lectures to various professional staff bodies in France, Sweden, Denmark and Holland who were considering setting up the model. The European Federation of Therapeutic Communities also saw its beginnings at that time.

I would like to record at this point that the personal cost of working in these projects for a number of staff was very high. I include myself in this. Rather like the residents in re-entry, it became sometimes very difficult to leave positively. Thought should be given to ways of 'de-toxifying’ from this type of project for staff who are wanting to leave as well as residents.

Nevertheless, the experience is one I shall never forget and I would like to thank the many graduates and staff who became, and still are, very dear friends, and who shared with me much personal growth at that time, which has now become part of my life. Probably in today's climate very little of the methods talked about in this paper could be incorporated in the treatment programmes of today without incurring someone complaining about 'breach of human rights'; although the 'human right' for a person to kill themselves with drugs when they are physically addicted and therefore not given any rational choice of stopping themselves is beyond me.

Considerable parts of the 'old Concept model' still do exist in some rehabilitation projects of today, which I suppose says something about its durability.

David Warren-Holland is founder and director of training at GCT Ltd (Groupwork Consultation & Training). David received his groupwork training at the Phoenix Institute NY, and also Europe and Great Britain. This covered a variety of social group/therapeutic models. He was a pioneer in the drug rehabilitation field, and was responsible with others for the early growth and development of two therapeutic communities in this country. For the last sixteen years David has worked as a social groupwork tutor/trainer in the health services, education and local authority settings, the voluntary sector, and probation service.

July 2000

Personal tools
radioTC international
what else is here?