Resident Self-Governance in Social Model Recovery Programs
Borkman, Thomasina, Contemporary Drug Problems
This paper focuses on governance processes, especially those by the "client" residents at Mustang River and Twelve Willows, the two social model programs in the process evaluation project. The philosophy of client/participant involvement in agency governance in social model programs stems from their roots in the democratic practices of Alcoholics Anonymous groups; this philosophy coincides with related developments in mainstream human services. The idea of client/consumer involvement in decision-making in health and social services has developed into a significant value since the 1960s, stemming from the civil rights movement, the war on poverty, the women's movement, and the consumer rights movement, among others; federal guidelines mandated patient and consumer involvement on review boards and other structures (Bordt, 1997; Weitz, 1996).
The potential problems of having client/consumer power shared with professionals or bureaucrats in an agency setting can range between two extremes. At one extreme the clients grab control or "run the asylum," as in the movie One Flew Over the Cuckoo's Nest. At the other extreme is sham client governance in which professionals allow the appearance but not the substance of patient involvement in decision-making. Between these extremes are varying degrees of delegation of decision-making to clients, with checks and balances provided by staff oversight.
Maxwell Jones popularized the idea of therapeutic communities in the 1950s with his experiments with patient-run groups in British mental institutions; the term "therapeutic community" became associated with the idea of democratic patient decision-making within an agency. To many observers Maxwell Jones's therapeutic communities signified shared power, with patients having meaningful authority in a context of staff oversight. However, Jones's therapeutic community was controlled by the top-down hospital bureaucracy. The patient-run groups at the bottom of the hierarchy operated within a limited sphere of trivial decision making (e.g., choices of leisure time activities). By 1976, in The Maturation of the Therapeutic Community, Jones made clear that patient-run groups existed at the staff's pleasure; when staff objected to their direction or decisions, Jones advised staff to simply terminate the groups. By the 1970s, Jones openly wrote that in effect therapeutic communities in mental hospitals constituted sham governance. Sham governance also occurred frequently in the 1960s and 1970s in "review boards" and other bureaucratic structures that were federally mandated to have patient/consumer involvement (Hasenfeld, 1992).
Another version of therapeutic communities (TCs) was independently developed in the U.S. drug treatment field, originating from the self-help program Synanon (De Leon, 1994) in the 1960s. The association of the idea of "therapeutic community" with democratic client decision-making that originated with Jones appears to have caused some confusion about TCs in drug treatment, though there is no relationship between Jones's form of TC and the U.S. version. The original American TCs emphasized a rigidly structured hierarchy up which successful residents climbed; they were referred to as "authoritarian," connoting a complete lack of client participation in agency decision-making (Sugarman, 1992). By the 1980s some TCs became less hierarchical, more "democratic," and less coercive (Rosenthal, 1989; Sugarman, 1992); "democratic" was defined in a narrow manner as more open communication between staff and residents with some shared decision-making, but no specific resident governance structures were mentioned (De Leon, 1994, 1995; Sugarman, 1992).
Some observers suggest that TCs in the drug field are similar to social model recovery programs in that they are both exemplars of sociocultural models (Institute of Medicine, 1990). TCs and social model recovery programs share important similarities in that the entire residential program is regarded as a therapeutic milieu, recovery is peer based, and recovering addicts are utilized as staff (Nebelkopf, 1993). …