Theoretical Frameworks

Since the model’s inception in the mid-twentieth century, the original philosophy of "community as method" has becoming increasingly explored through various theoretical and evidence-based frameworks. Successes in recovery are met through applications of behavioral methods, psychodynamic theory, and social cognitive learning principles discussed below.

In order to achieve social cohesion among its 1,500 residents, SanPa relies on direct behavioral methods. Operant-learning techniques, a type of behavioral learning, are used to enforce group and individual behaviors in accordance with SanPa’s rules/regulations. When residents perform behaviors in line with community goals, they are provided positive feedback (e.g. privileges or rewards) that enables their progression in the program. On the other hand, they are disciplined for behaviors that run contrary to the overall goals and safety of the program (e.g. negative punishment such as removal of privileges, or positive punishment such as application of sanctions). This behavioral feedback also supports cognitive schema changes regarding what is acceptable and unacceptable in the community, thereby further driving motivations for social cohesion 56.

Though the above shaping is highly influential in facilitating individual change, there are additional mediators of recovery that are rooted in psychodynamic theory. This can be best appreciated through examination of the peermentoring relationship. As residents advance in treatment, they serve as mentors for those entering the program and this pairing is maintained for the first year of the new resident’s stay. Consistent mentoring provides a sense of usefulness for these more advanced residents, thus providing a sustainable form of gratification unlike those previously attained through drugs. The mentees also draw significant benefit. For many with SUDs, there are often co-occurring difficulties associated with behavioral and emotional self-regulation 57 58 59. According to the psychodynamic therapeutic model, it stands that self-regulation is best supported when one is in the company of those who hold capacities to self-regulate amidst similar stressors. This is best supported by Donald Winnicott’s theory of the "holding environment", in which available caretaking acts (e.g. active listening and emotional attunement) foster trust and safety for the individual to explore themselves 60 61 62. Because the mentor is likely more advanced and self-regulated in their recovery, they are able to offer support to those who might not be able to work through difficulties on their own. The safety inherent in this unique relationship generates ‘potential space’ in which the resident can explore and work through inner conflicts, as well as the painful emotional states that have led to their drug use 63.

Benefits of the peer-mentorship are also consistent with Wilfred Bion’s theory of the "contained/container", whereby the mentor transforms the mentee’s overwhelming affective state to an experience that is more tolerable 64 65. Research suggests that emergence of negative emotional states often precipitate the turn to drugs, both in casual and problematic situations 66. Through their relationship, the mentor lends ego support to the new resident, thus allowing time and space for processing of a particular topic without them needing to take on the burden of the full emotional experience. Thus, this gradual and safe relief of pain through "peer therapy" ultimately creates new, healthy associations of pain release that are divorced from their historical drug use. New components of identity begin to slowly emerge and therefore strengthen their growth in recovery.

Another strong mechanism of therapeutic effectiveness within the community model is that of observational and vicarious learning. This occurs when an individual acquires skills, information, or behavioral patterns through direct observation of others in their environment. 67. At SanPa, daily interactions with peers enable one to "look at themselves within others" 24-hours every day of the week. Unlike one-on-one treatments in an often-sequestered professional setting, San Pa provides a more robust opportunity for rewiring of healthy attachment patterns, as a result of the abundant dynamics encountered in the community 68. Furthermore, such ongoing encounters and reflections on the mental states of others is thought to improve mentalization and reflective functioning. Defined as the "uniquely human capacity to make sense of each other", exercises in reflective functioning enable residents to more appropriately align their behaviors with their mental states, therefore promoting more meaningful ways to communicate in their relationships at SanPa 69.

  • 56. Doogan, N. J., & Warren, K. (2016). Semantic networks, schema change, and reincarceration outcomes of therapeutic community graduates. Journal of substance abuse treatment, 70, 7-13.
  • 57. Baumeister, R. F., DeWall, C. N., Ciarocco, N. J., & Twenge, J. M. (2005). Social exclusion impairs self-regulation. Journal of personality and social psychology, 88(4), 589.
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  • 61. Winnicott, D. W. (1988). Human nature. London: Free Association Books.
  • 62. Debaere, V., Vanheule, S., & Inslegers, R. (2014). Beyond the "black box" of the Therapeutic Community for substance abusers: A participant observation study on the treatment process. Addiction Research & Theory, 22(3), 251-262.
  • 63. Winnicott, D. W. (1991). Playing and reality. Psychology Press.
  • 64. Bion, W. R. (1962). Learning from Experience. London: Heinemann. Seven Servants: Four Works by Wilfred R. Bion.
  • 65. Bion, W. R. (1970). Attention and interpretation: a scientific approach to insight in psychoanalysis and groups. London. UK: Tavistock.
  • 66. Koob, G.F., & Volkow, N.D. (2010). Neurocircuitry of Addiction. Neuropsychopharmacology, 35(1), 217-238.
  • 67. Bandura, A. (1997). Self-efficacy: The exercise of control. W H Freeman/Times Books/ Henry Holt & Co.
  • 68. Perfas, F. B. (2014). Therapeutic community: past, present, and moving forward. Hexagram Publishing.
  • 69. Fonagy, P., Gergely, G., & Jurist, E. L. (Eds.). (2018). Affect regulation, mentalization and the development of the self. Routledge.

Weill Cornell Medicine Program for Substance Use and Stigma of Addiction 1300 York Avenue New York, NY 10065 Phone: (212) 746-3738