Standards Domains
INTRODUCTION
This chapter presents a provisional list of standards for TC programs in prisons. The standards are organized into 11 domains. For each domain, there is a general standard reflecting an essential element or overarching principle of the TC approach. This is followed by a general rationale or intent of the standard and the list of specific indicators, or performance measures, of the general standard.
A. THEORETICAL BASIS
T. It is essential that programs operating as TCs have a solid grounding in the existing professional literature which describes the TC (history), theory and treatment model.
General Rationale/Intent
The TC Perspective consists of four broad views which guide its approach to the treatment of substance abuse and related problems: the view that substance abuse and criminality are symptoms of a disorder of the whole person, the view of the person which consists of the social and psychological characteristics which must be changed, a view of "right living." the morals and values requirements which sustain recovery, and a view of recovery from addiction as a developmental learning process. These views define the unique, characteristic manner in which the therapeutic community approach differs from other forms of treatment.
Standards
T1. The program has a package of written orientation materials that includes a statement of program philosophy that is consistent with the TC perspective.
T2. The program openly displays TC slogans and teachings and promotes prosocial values of 'right living,' including: truth, honesty, self-responsibility, work ethic, community responsibility, responsible concern for peers, etc.
T3. The program handbook or manual should provide an explicit and comprehensive section on the TC perspective on the substance abuse disorder. Substance abuse and criminality are seen as symptomatic behavioral problems that are secondary to the disorder of the whole person.
T4. The prevailing attitude in the community is a sense that the participant needs to make major, conscious life changes, rather than that the person is 'sick' and in need of care.
T5. Participants and staff clearly acknowledge and identify common personality and behavioral traits shared by all (incarcerated substance abusers).
T6. Abstinence is seen as a prerequisite to recovery, as evidenced by a substance-free environment.
T7. Recovery is discussed as an on-going process, continuing after treatment.
T8. TC prison programs have a clearly defined, written glossary of program terminology based upon general TC and program-specific sources that is given to participants upon entry, as well as to clinical and security staff at onset of employment.
B. GENERAL CLINICAL PRINCIPLES
CP. It is essential that program participants identify with the TC and feel a sense of belonging in order to change their patterns of criminality and substance use. There must be a continuous (i.e., 24-hour) atmosphere of constructive confrontation and feedback to individuals and the community as a whole, in order to raise personal awareness of the individual's behavior and attitudes.
General Rationale/Intent
The TC approach to substance abuse treatment is a psychosocial, experiential learning process which utilizes the influence of positive peer pressure within a highly structured social environment. The primary therapeutic change agent is the community itself, including staff and program participants together as members of a "family." The culture is defined by a mutual self-help attitude where community members confront each other's negative behavior and attitudes and establish an open, trusting and safe environment where personal disclosure is encouraged, and the prison culture of the general population is rejected. Participants need to view staff as role models and rational authorities rather than as custodians or treatment providers.
Standards
CP1. The primary approach to treatment is "community-as-method."
CP2. The prevailing moral imperative is "I am my brother's keeper" as opposed to the prison culture attitude.
CP3. Both TC staff and security staff are seen as members of the community, with different roles and responsibilities.
CP4. Participants are aware of each other's treatment goals and objectives and help others to achieve personal growth toward their goals.
CP5. Treatment activities emphasize experiential learning (direct and vicarious); "doing" rather than "getting" therapy.
CP6. Participants are accountable to each other and the community on a continuous basis, fostering a strong sense of responsibility for self and others.
CP7. The locus of control is shared between staff and program participants. However, the staff maintains ultimate authority, and applies it in a rational manner.
CP8. A major focus of participant learning is on the development of affective skills, including the ability to identify and express feelings in a prosocial manner.
CP9. The counselor's interactions with program participants are both formal and informal (e.g., role modeling).
CP10. Staff counseling techniques include didactic, personal sharing and redirecting members to the peer-community process.
CP11. Program participants are strongly encouraged to self-disclose personal issues and observations about the community, in keeping with prison and TC guidelines.
CP12. Participants maintain strict confidentiality between the program and the general prison population.
CP13. Positive feedback such as encouragement is provided more frequently than negative feedback.
C. ADMINISTRATION
AD. It is necessary that key administrative and management staff who interface with the contracting agency have a full understanding of the TC, and function synergistically in order to maximize the effectiveness of the program.
General Rationale/Intent
In a TC, all staff, including administrative and support staff, are part of the community and therefore need to fully support the principles and practices of the TC process. In an in-prison TC, the contracting agency responsible for the program operation is usually not located at the site, except where the corrections agency is the sponsor. It is assumed that the agency is accountable to the public funding agency in terms of administrative requirements, including any licensing standards. It is also assumed that the facility is certified through other standards for correctional facility operations. There are general administrative standards which are specific to, or have a significant impact on, the TC program.
Standards
AD1. The agency maintains written administrative policies and procedures that are known to the staff, and are updated at least annually.
A2. The agency has a written quality assurance plan that insures corrective action takes place in a timely fashion.
AD3. The program reflects inclusion and respect for all, regardless of cultural background, gender, age, race, sexual orientation, criminal history and medical status (e.g., HIV).
AD4. The program prohibits practices that are demeaning to a program participant or that otherwise conflict with minimum standards of correctional care.
AD5. Each participant has a written treatment plan which is reviewed and updated periodically in accordance with the planned duration of treatment and phases of the program.
AD6. The agency is committed to documenting the effectiveness of treatment through identification of, and collection of data on, relevant outcome indicators.
AD7. The agency maintains clinical records in a manner which meets regulatory requirements, but also facilitates clinical work.
AD8. Confidentiality is strictly maintained in the handling of all client-identifying materials (reference: federal regulations, 42 CFR, part 2).
AD9. The facility is properly licensed, accredited and/or certified as may be required by appropriate state agencies.
AD10. The program has sufficient financial support and resources to enable it to maintain the integrity and autonomy of the therapeutic community process while insuring safe integration into the prison population.
AD11. The program has written "cardinal" rules (no sex, violence, substance use, etc.) which, if violated, may result in termination.
AD12. The program length-of-stay is adequate to provide necessary rehabilitation and preparation for re-entry, but not beyond the point of diminishing returns, as is optimal indicated by research (9-12 months or 12-18 months etc.).
AD13. There is an ongoing effort to support each participant's staying in treatment long enough to have the desired effect.
AD14. There is a written policy and procedure that insures that program participants may leave the program voluntarily.
AD15. The entire staff meets and communicates regularly in order to address clinical issues and to assess the functioning of the TC process.
AD16. TC management meets regularly with the warden/superintendent and senior Corrections staff to insure proper communication.
AD17. The TC provider and Corrections officials (e.g., warden) negotiate the following:
- allowing program participants to express feelings openly, and loudly, if necessary
- shared locus of control between staff and program participants
- procedures for program participants' involvement in disciplinary handling of other program participants
- maximizing the number of TC program hours per day (operating 7 days per week when feasible)
- allowing informal/formal staff-program participants interactions that might be considered "fraternization" in the prison setting.
- written monitoring protocol about systematic accountability to prevent staff/participant-clinical boundary problems.
- allowing program participants to perform maintenance and cleaning of the program space--broaden scope of program TC work readiness job functions.
- clarifying the criteria for selecting client candidates who are appropriate for the program
- establishing referral procedures in order to maximize utilization of program slots and to achieve optimal outcomes.
AD18. Efforts are made to insure that TC members maintain the respect of general prison population (e.g., by competing in sports, etc.).
AD19. An incident reporting protocol that distinguishes which incidents/member behaviors are directly addressed by the program and how they are reported and managed by clinical and prison security staff.
AD20. The warden and senior correctional staff permit access to the program by interested outside parties.
AD21. The warden/superintendent and senior correctional staff understand the program and support its objectives.
AD22. Clinical records of program participants are not merged with their general prison file, but are fully protected by confidentiality regulations.
D. STAFFING
S. It is essential that the entire staff function in a manner that is consistent with the philosophy and practice of the TC.
General Rationale/Intent
Ideally, the majority of clinical staff should be graduates of a TC. In any case, there should be a mixture of recovering and non-recovering staff, including graduate-level professionals and ex-program participants, who complement each other in a unified way. There needs to be full support for the integrity of the TC at all levels within the funding and sponsoring agencies, including administration. In order to insure that the TC maintains its effectiveness, there must be initial and ongoing TC-specific training. Security and TC staffs need to be sensitive to each others' needs and approaches.
Standards
S1. The clinical staff includes recovering addicts and/or ex-offenders, preferably graduates from a TC, who act as positive recovering role models.
S2. Staff who are not in personal recovery are fully initiated and integrated into the TC concept and act as role models.
S3. At least one key management or senior supervisory staff person is a TC graduate, where this provision is feasible under state regulations.
S4. There is a TC staff orientation program consisting of at least 30 hours of didactic and experiential (e.g., immersion) training required for all employees, and an ongoing schedule of in-service and TC-specific training activities.
S5. Key administration officials from the contract agency and from the public agency and institution receive a minimum of 15 hours of TC-specific training, including both didactic and experiential.
S6. Clinical staff are appropriately certified as may be required by state regulations, and all staff are encouraged to obtain TCA certification.
S7. TC and security staff receive cross-training, i.e., TC staff receive security training from the public agency and security staff receive TC-specific training through a qualified provider.
S8. All clinical staff receive at least 2 hours of individual and 6 hours of group clinical supervision per month.
E. FACILITY/ENVIRONMENT
FE. The environment should support the primary identification of program participants with the TC culture in contrast with the prison culture.
General Rationale/Intent
The atmosphere within the TC facility should be one of safety, identification and caring. Participants should be enabled to take full responsibility for the TC space, maintaining it with a sense of ownership, pride and quality. Participants should be allowed to clean and maintain the facility as much as possible, including painting, decorating and repairing. It is important that the physical space reflect the care and concern which program participants in the TC demonstrate toward each other. When something is broken, it should be fixed immediately.
Standards
FE1. To the extent possible the program should be a self-contained environment within the larger prison setting. The treatment program is situated in special housing and space and there is minimal mixing of the treatment participants with the population in the recreational yard or at mealtimes.
FE2. The facility meets all applicable fire/safety and building codes, and local, state and federal regulations, including licensing requirements, as may be required.
FE3. The facility is clean, safe and adequate in space to meet the needs of the TC program.
FE4. Throughout the TC space, there are highly visible signs, slogans and symbols indicating a common philosophy, purpose and identification.
FE5. Larger TC programs are subdivided into units no larger than [50-75].
F. TC PROGRAM ELEMENTS
TC. All TC program components are structured to address the common socialization and psychological needs of program participants.
General Rationale/Intent
Every element and activity in the TC has multiple purposes, including: community building, education, increasing self awareness and self esteem, developing employment and independent living skills and improving interpersonal skills. Participant interactions are maximized through the emphasis on group activities. Participants may lead many of the activities under staff supervision.
Standards
TC1. There is a hierarchical stratification of program participants which establishes levels of responsibility and status by job functions. A TC organizational chart and structure board is posted in the main area of the program, managed by peers under staff supervision.
TC2. Participants perform all possible house chores, e.g., cleaning, maintenance, clerical, expediting, etc.
TC3. Work is used to support the program goals and to reinforce the sense of community and individual self-esteem.
TC4. A key clinical focus of job functions is development of appropriate attitudes and values concerning work, and skills for resolving interpersonal conflict, especially those involving authority relationships.
TC5. The program uses groups as a primary clinical intervention, including: encounters, probes, marathons, tutorials, etc.
TC6. Therapeutic peer groups and topical theme groups are held at least weekly, allowing program participants to help each other toward their individual treatment goals.
TC7. Staff counselors meet individually with program participants on at least a twice-monthly basis.
TC8. There are daily points of interaction between staff and program participants that indicate a shared mission and experience, (e.g., meals, recreational activities, holiday observances).
TC9. There are daily morning meetings which serve to motivate and energize program participants.
TC10. Meetings are held daily in which community business either is or can be transacted.
TC11. General meetings occur ad hoc to address negative behaviors, extraordinary positive behaviors, incidents or attitudes, and include the entire house.
TC12. Program participants and staff engage in meaningful program rituals, traditions and rites of passage.
TC13. The program includes daily, participant-led seminars which enhance independent living skills.
TC14. Conflict resolution, anger management and decisionmaking skills are taught throughout the clinical program.
TC15. The program provides formal relapse prevention training.
TC16. The program integrates health/mental health services with appropriate modifications to the clinical program to accommodate special needs.
TC17. The program provides appropriate educational assessment and instructional services on site.
TC18. The program provides health education training in both prevention and control of threatening diseases.
TC19. The program provides appropriate vocational training, including job preparation.
G. TC PROCESS
TP. The process of change in the TC unfolds as an interaction between the individual and the community. Socialization and personal growth occurs when individuals meet the community expectations of participation in all program activities and all social roles.
General Rationale/Intent
The TC is run primarily by positive peer pressure and group process. Participants check each other's behavior and attitudes on a continuous basis. Through constant interaction, the TC population provides feedback and confrontation aimed at raising personal awareness, particularly of the effects of one's behavior on others. This leads to increased community responsibility and accountability.
Standards
TP1. To strengthen trust in the program, the staff guide program participants to use the community process.
TP2. Senior program participants take a responsible role in relation to junior program participants, including roles such as: running house meetings, orientation of new program participants, and other peer and house management functions.
TP3. The program culture fosters the development of interpersonal relationships to facilitate individual change.
TP4. Program participants are viewed as brothers/sisters, and interpersonal relationships of a romantic or sexual nature are considered taboo.
TP5. Much of the actual help received by program participants is through informal interactions between program participants in the course of daily activities.
TP6. Peer feedback occurs more frequently than staff counseling.
TP7. The prevailing mode of interaction is positive peer pressure, including confrontation and supportive feedback aimed at changing negative behavior and attitudes.
TP8. Participants and staff work together to solve community problems; program participants have meaningful input into program planning.
TP9. Participants are encouraged to "act as if" as a means of developing a positive attitude.
TP10. The program allows some contact with the general prison population (e.g., mess, recreation) so program participants can test their clinical progress outside the boundaries of the program space.
H. STAGES OF TREATMENT
ST. The protocol prescribes at least three major program stages: induction, primary treatment, and re-entry. These are structured in order to facilitate a developmental process of change.
General Rationale/Intent
Meeting the goals and objectives of the prescribed program stages facilitates internalized learning until the individual actually incorporates a new identity which is consistent with the principles of right living. Moving through the stages of compliance, conformity, commitment and integration, the individual's motivation changes from external to internal. In prison TC programs, re-entry is modified, depending upon the circumstances of the jurisdiction. Ideally, there is a separate living space for re-entry program participants until they are released to a community-based program.
Standards
ST1. The program is designed in three main stages, each with clearly defined written goals, activities and participant expectations.
ST2. Activities of the orientation/induction stage are aimed at assimilating the new participant into the community.
ST3. Orientation program participants may receive lesser consequences in order to assist them in adjusting to, and engaging in, the TC process. This phase has more of a psychoeducational focus.
ST4. There are written criteria for testing program participants for passage into the primary treatment stage--which is celebrated as a rite of passage.
ST5. Major goals of primary treatment include full incorporation into the community process, focus on abstinence and psychological growth.
ST6. The primary treatment stage emphasizes full use of the positive reinforcement of privilege and status level systems.
ST7. Participants develop good work habits and values and job readiness skills, strengths in interpersonal relationships in the workplace and resolve authority relationship problems in order to improve employability.
ST8. The major clinical focus of re-entry is preparation for transition to independent living outside the TC, through education and life skills training, followed by employment.
ST9. Re-entry program participants develop a commitment to continued treatment and support systems in the community, as well as concrete plans to obtain these.
ST10. Re-entry program participants are fully oriented to 12-Step recovery support groups (e.g., NA, AA), relapse prevention technology and alternative support groups.
ST11. The provider agency maintains qualified service agreements with a network of community-based aftercare resources.
ST12. The program maintains positive relations with community corrections and justice agencies responsible for follow-up treatment and aftercare services in the community.
ST13. The program initiates joint discharge planning with parole and/or other community supervision staff at least 90-120 days prior to a participant's release date.
I. COMMUNITY TC AND CLINICAL MANAGEMENT
CM. The psychological and physical safety of the community is the responsibility of both program participants and staff.
General Rationale/Intent
Management of participant behavior requires full participation by all program participants. The behavior modification system includes a balance of negative and positive rewards which are applied in a consistent, predictable, immediate and rational manner. Senior program participants are involved as a team in confronting individuals and investigating incidents in order to determine responsibility. Participants are expected to engage in continuous checking of each other's behavior and attitudes.
Standards
CM1. There are written behavioral norms which govern participant behavior.
CM2. Graduated sanctions for violation of rules are well defined, and known by all program participants.
CM3. Participants are involved in handing out behavioral consequences and earned privileges to the extent possible, under staff supervision.
CM4. There are clearly defined privileges, e.g., status advancement, more desirable living space, which are earned based upon clinical progress.
CM5. Choices of privileges are supportive of the principles of recovery and "right living."
CM6. Negative behaviors and attitudes are confronted immediately and directly by peers. This practice is seen as acceptable to the community, is reinforced by it, and acts to neutralize prison culture attitudes.
CM7. Critical feedback is directed at negative behavior and attitudes, not at the individual's character.
CM8. Participants enter into treatment contracts which include contingencies for behavioral consequences (e.g., lesser housing, less desirable job, etc.).
CM9. The program requests urine drug testing of program participants, conducts tests on staff for probable cause, and requests the results of all urine drug screens conducted.
CM10. There is a system of regular house-runs which keeps continuous track of the whereabouts of all program participants.
CM11. In conjunction with correctional staff, the program screens belongings and conducts "dorm runs" in order to minimize the presence of contraband and drugs.
CM12. Supervisory staff regularly conduct random observations of the main clinical activities (analogous to random urine screens) to sustain quality. These are recorded in the file with date, activity, and overall rating of the activity.
J. INTAKE SCREENING AND ASSESSMENT
SA. It is essential to assess the primary problem area of program participants admitted to the program. This includes obtaining a history of substance abuse and related criminal activity, other offenses and mental health. In addition, the program should have an ongoing mental health screening capability.
General Rationale/Intent
The TC approach has been adapted for a wide variety of social and psychological problems in addition to substance abuse. However, certain subgroups of substance abuser may not be suitable for the socialization and psychological demands of community life. For example, program participants who are actively violent or severely mentally ill pose threats to the safety, or make excessive management demands upon, the peer community.
Standards
SA1. The program has written eligibility criteria agreed upon by the sponsoring agency and corrections officials to identify participants most likely to benefit from the program.
SA2. Residents conduct outreach activities within the general prison population.
SA3. There is a standardized admission screening and assessment format, which may include interviews with senior program participants.
SA4. Mental health screening is conducted by qualified staff.
SA5. The program has the authority to reject inappropriate and unmotivated applicants.
SA6. Staff conduct a thorough biopsychosocial assessment within 10 days of admission, which includes identification of the program participant's strengths and weaknesses.
K. COMMUNITY-BASED AFTERCARE
AC. There must be appropriate community-based aftercare of at least 6 months duration after release from prison TC programs.
General Rationale/Intent
Research clearly demonstrates the importance of aftercare programs to maintain the positive gains made in the prison TC. Ideally, these programs include a TC-oriented residential setting which enables the former participant to transition back into the community successfully. However, other forms of aftercare with documented effectiveness may be appropriate for some prison TC graduates.
Standards
AC1. Minimally, each participant has a written aftercare plan co-authored by staff and program participant, which includes community treatment and support group participation.
AC2. Where available, program participants are referred to a community residential facility for a minimum of 6 months duration.
AC3. Urine surveillance is available for at least the first 3 months of aftercare.
AC4. Whenever possible, family counseling is provided as part of the aftercare plan.
AC5. Participants sign a release form to allow for follow-up by the sponsoring agency.
AC6. The prison TC has a written agreement with the specific community agency to which the participant would be referred.
