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Therapeutic Communities and High Functioning: An Interview with Dr. Westley H. Clark

The Director of the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA), Dr. H. Westley Clark, M.D., J.D., M.P.H., graciously took time out recently to participate in an informal telephone interview for the TCA News. The interview’s topic was open-ended; Dr. Clark was asked to speak generally about the role of the therapeutic community in the future as the face of addiction continues to change. In answer, Dr. Clark covered a lot of territory with warmth, insight and evident commitment. What follows are a few highlights from that conversation.

What is the Future Role of the Therapeutic Community?
Dr. Clark begins the interview by pointing to those TC programs that are diverse and responsive to the various needs of the individuals who benefit from services – then he turns the question around. "I think the therapeutic community ((ITALICS))community ((END ITALICS)) plays a major role in deciding what its future role will be," he says. "It’s clear that TCs can be adapted to the changing marketplace if you will. They themselves will play a major role in deciding what they should do and how they should function."

Domains of Function
"Domains of function" is a recurring theme throughout the interview. In terms of drug treatment, Dr. Clark defines them as the range of services that encompasses education, medical services, rehabilitation services and vocational services – anything which raises an addict’s level of functioning.

Domains of function concern Dr. Clark for a couple of reasons. First, they dictate the ultimate success and opportunity made available to the client after treatment. They also influence how the efficacy of drug treatment is perceived to people outside the treatment community. They "allow the community in general – society – to accept that treatment works and that treatment offers hope to people," says Clark. "We return people to a level of function where they’re making contributions and they’re not seen as draining resources away from other things."

Special Populations
To whom does the term "special populations" refer? In no way exhaustive, the list includes "parents, pregnant women, homeless people, juveniles… people who need a safe environment in which to function." Nonetheless, this interview turns to two groups in particular: parents and those in the criminal justice system.

Dr. Clark is clearly excited about some of the TC components for addicted parents and their children that are popping up around the country. He urges these programs to continue helping mothers demonstrate their abstinence to child protective service agencies. Closer to home, Dr. Clark speaks about the importance of parenting education and "the enhancement of parental skills so that children grow up without any kind of emotional deprivation beyond what they’ve already suffered."

As for dealing with criminal justice issues, Dr. Clark encourages TCs to remain assertive while advocating for pre-trial diversion so that addicts aren’t convicted with felony violations. "We’re concerned with felonization and criminalization," he says, pointing to the fact that stigma is an issue that denies felons opportunities that are available to other recovering addicts. "In the end, if all that happens is that they go out and all the doors shut in their faces because the computer comes up ‘felon’ or ‘criminal,’ then our purpose is ultimately defeated."

What Can TCs Do to Help Addicts Obtain a Higher Level of Functioning?
Generously, Dr. Clark maintains that therapeutic communities are already doing much of what’s needed to help addicts increase their levels of functioning. By design, most TCs address a broad spectrum of clients’ life and work skills that fit within domains of functioning categorization. Additionally, TCs "isolate from the toxic environment of substance abuse" providing the necessary time and focus to enhance clients’ functioning levels.

To demonstrate this point further, Dr. Clark refers to recent research. "We now know conclusively that some of the neuropsychological effects of chronic addiction persist for six months to two years," says Clark. "A therapeutic community allows people to reconstruct their lives over a sufficient period of time so that they can gain adequate recovery of their neuropsychological function."

How Can TCs Become More Effective?
To be effective both politically and programmatically, Dr. Clark puts current events at the top of his recommendations list. "This is not specific to TCs," he says. "Any provider has to keep current with the clinical issues."

Next, he maintains that the benefits of interacting with the community and with public agencies are well worth the required energy. In his experience, when a therapeutic community remains involved, it can play an integral role in the fabric of the local community, as well as in the national dialogue on developing drug treatment strategies.

In making his third recommendation, Dr. Clark first cautions that TCs aren’t exempt from dogma. "They have to deal with their own philosophical inclinations," he says. If you’re going to change, then that change must "be based on your own information, your own traditions, your own histories so you don’t get fads. You get progressions that are logical, sustained and meaningful."

Finally, Dr. Clark reiterates his appreciation of the therapeutic community approach to treatment. "I see TCs as being very creative and responsive as time passes. In the next five years, TCs certainly will be at the table, they belong at the table, and I have no reason to believe that this will be changing."

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