How to prevent your TC from falling apart

It just dawned on me the other day that this coming June, I will have achieved 17 solid years of sobriety. With all these years spent in Therapeutic Community (TC) development, I felt it was time that I contributed some of my experience towards the cause of the TC. This article is dedicated to all my colleagues who are either starting a TC program or have been running one for some time now. I hope that you will be able to relate to some of my experiences and I trust that it will help validate your noble endeavors.The TC Phenomenon

Establishing a new TC program is the easy part. Sustaining its culture through the years, however, is another story. During its initial years, the program structure can get refined and systems undergo improvement. Within the first few years, one can claim that a program’s culture is finally working well. The trouble is, down the road, things can change radically if you’re not careful.

If you’ve been running your TC program for some time now and you’re noticing that it doesn’t feel like the one you’ve set up a long time ago, you might want to look into some of the areas described below.

Over time, TC systems and rules have a way of getting altered without you knowing about it when you don’t have a systems check program. When this happens, you can lose the very heart of your TC and the integrity of your program could be put in question. The thing is these developments have a way of creeping up on you without warning and one day, you’ll just wake up and wonder what happened.

This retrogressive process is something you’ll notice you can’t hang on anybody. By the time you discover this, you’ll find out it’s been there for months or even years. Its so ghostly that I’ve decided to call it a TC phenomenon.

We at SELF have had to face this predicament at least three times over the last 16 years. We have had to review our organization’s culture repeatedly to maintain the goodness of the program. Though our efforts were rewarding, they were time consuming and we decided it was time to develop a system that checks systems.

No Available Model

Numerous training programs on the TC were held in Asia in the last two decades. In the 90s, a sudden slew of training opportunities on the TC program were made available to operators from all over Asia. During this period, the aftercare program was conceived followed by the development of family programs.

The new millennium saw a rapid increase of rehab centers in Asia and, consequently, everyone got concerned about the quality of service being provided by many. Towards this end, training programs began focusing their efforts on the establishment of minimum standards for running programs.

In the Philippines, it was around this time when our government’s Department of Health (DOH) came out with a comprehensive manual that regulated rehab centers. Because of this, treatment centers from all over the country began to reevaluate their respective programs in order to comply with regulations and get accredited by the government. But to this day no one has created a suitable program that automatically checks and balances the systems and culture of a program.

Last year, we took the challenge to develop a check and balance mechanism that will prevent the decay of our TC program. Today, we seem to have a better grip on things and our program feels like it never faded a day. Here are four most common symptoms we’ve discovered along with a few ideas you might want to try in order to prevent your TC from falling apart:

1) The Pendulum Syndrome

Part of the phenomenon we observed about TCs is that some practices tend to swing from strict to lenient, or from always to never. One day you’re making a rule a bit stricter and later discover that the community has taken the rule to the hilt. Now, you’re wondering why the rule is so unreasonably strict.

So you’ll try and fix the problem by flexing the rule a bit only to discover that after many months, the community had unwittingly become too relaxed. I call it a phenomenon because, somehow, there’s never a middle ground. Like a pendulum, practices have a way of swinging from one end to the other.

2)      Rules Get Invented

Would you believe it if I told you that rules get invented unofficially over time? Well, they do. If you look carefully into every rule, habit or tradition in your program, you’ll notice that someone in your community has inadvertently invented certain rules that, in fact, have never passed the scrutiny of management.

Some months ago, we discovered that two out of six toilets were designated for urinating only. When confronted, most residents claimed the rule had been there since they arrived.

Here’s why we think this happens. Residents normally like to avoid confrontation and in order to lessen the chances of such discussions on the proper use of toilets, they’d rather make rules or agreements to make life easier in the TC. Off the bat, there’s nothing wrong with that except for two things.

One is that they fail to communicate the initiative and instead allowed a rule to be established arbitrarily. The second is that they end up disregarding the therapeutic purpose behind learning how to discuss toilet use issues among peers.

3)      LEs Turn into Practices

Another phenomenon we observed is that Learning Experiences (LE) get turned into practices or even policies—again without the approval of management. A funny thing happened when we ran our last workshop on Rules, Habits and Traditions. We discovered that residents were being made to finish their share of the food allocation. That meant that if the Kitchen was serving two packs of biscuits, you’d have to finish them, no ifs and buts. During meals, everyone had to consume their allocation of say, one chicken leg, a cup of rice and vegetables. If you were not hungry, well … it could be trouble for you. This was the understood rule.

When I began investigating this development, I was once again stumped because I found out it had been existing for over a year. After extensive discussion, we discovered that long ago the Kitchen Department was seriously sanctioned for throwing away a whole bowl of spaghetti. Their LE: to make sure they calculated the food that was going to be consumed everyday for the next four weeks. Their guideline: no leftovers. Evidently, this LE was never lifted.

4)      Change from Staff to Staff

This fourth observation, though last, is I think the most important one. If rules are not clearly written and made available for everyone to see and understand, who’s to know what could happen when the TC was under the watch of someone other than your most trusted staff?

Managing a TC is not easy. Staff members are highly prone to burnout. Their effectiveness is limited by their strengths as human beings. No training in the world can prepare a person to take the helm of a TC and remain objective without monitoring and review. That is why it is imperative that a Procedure Manual be constructed that contains every single rule, habit or tradition together with all possible forms of consequences and interventions.

At the start of each year, we at SELF review this manual in plenary to prevent opportunities for abusive practices by staff.

Suggested Solutions:

If you can relate to some of the examples above, here are some of the things you might want to do:

1) Conduct a complete culture review of your organization. Get into a healthy discussion on the objectives and core values of your organization.

2) Establish a motto that best describes your culture. In our case, it is Strict yet Caring.

3) Compose easy guiding principles that will govern the way you do things in the entire organization. We at SELF have created a three-way test. Anything we do in the organization must conform with being Respectful, Logical & Practical.

4) Conduct a series of workshops aimed at reviewing all the program and admin protocols. Examine each and every rule, habit, tradition, guideline and procedure. Include some of the residents. This is usually very educational for them.

5) Compose a Procedure Manual that contains not only the rules and policies but the protocols in handling situations as well.

Expand your House Rules guidelines. Every TC today usually has the same basic House Rules as inherited through generations. It is time that you learn to develop your own to suit your facility and program.

Sustaining the Culture

Once you’ve established the new culture and your systems and procedures are in place, you’ll want to find a way to sustain it. Otherwise, you might see yourself doing this process all over again in the next few years. Here are some helpful hints:

1) Conduct positive surveys. You want to get direct and anonymous feedback about your program in all facets. Make one for your primary, secondary and aftercare programs. Ensure that the residents are kept safe in answering the info sheets.

Conduct one for families and include the entire inquiry and admission process as well. Study the results objectively and make recommendations.

2) Create a Key Result Area (KRA) monitoring system. But before this, you must first arrive at KRAs that best indicate whether your program is on track or not. These indicators are not easy to develop and therefore you must convene a group of your most experienced staff. Meeting at regular intervals, you can discuss and review. Are you meeting the deliverables?

3) Create a Behavior Tracking Sheet (BTS) or consequence recording form. Make sure every resident has one and knows the progress of his/her sanctions and LEs. Devise a Rule of Thumb system of reducing consequences when positive behavior is achieved.

4) Develop a methodical procedure for amending the rules and policies in your Procedure Manual. Include regular House Meetings in the annual schedule with the aim of thoroughly discussing your rules, habits and traditions.

5) Do actual sit-ins on the daily activities and group sessions of the TC program. You’ll be surprised how much you can discover when you’re closely in touch with your residents.

In Closing

Getting down and dirty, as they say, is the only way through these challenges. I’ve been doing this work for nearly 17 years now and, surprisingly, my passion is continously growing. I’ve got 24 staff members in the organization, more than 70% of whom are assigned to the facility. Still, I spend an average of two to three days a week conducting meetings, seminars, workshops and discussion groups there. And when I’m done, I try to strike simple conversations with some troubled residents.

When was the last time you even sat in the Morning Meeting?

MARTIN R. INFANTE
President, SELF
May 2008