An Open Letter from Bill Bailey
Recently, we have received several inquiries about Cenikor’s approach to substance use disorder that all seem to be seeking a better understanding of the Therapeutic Community component of our program. As such, I want to share the following white paper that addresses the major elements of the Therapeutic Community program and the crucial role it plays in Cenikor’s mission to provide a foundation for people with substance use disorder to achieve better health and better lives.
President and CEO
Understanding the Therapeutic Community Model
Cenikor Foundation is a place for change that provides a foundation for better health and better lives. Our Therapeutic Community treatment program is an 18 to 24-month program licensed and regulated by the Health and Human Services Commission (HHSC) of the State of Texas. The length of the program is designed to support individuals who have long-term substance use disorder and/or behavioral health issues. In Texas, this treatment program is governed by regulations in the Texas Administrative Code, Title 25, Part 1, Chapter 448. In Louisiana, the Therapeutic Community is governed by the Louisiana Department of Health and Hospitals and has a similar code.
Per these regulations, the Therapeutic Community (TC) methodology to treatment is distinguished from other models of care by the following:
The regulations Cenikor follows are used to provide a treatment environment to support recovery from substance use disorder and support healthy/right living. “Right living” is defined as a set of primary values which include honesty (in word and deed); taking responsibility (assuming a level of personal responsibility for the recovery of their peers and self); work ethic (work is considered a critical therapeutic and educational activity in the TC); and learning as a value (education is stressed as essential for both formal and informal learning). All experiences in recovery can be used to learn about oneself and advance personal growth.
In the Therapeutic Community, clients serve as peer support by using peer identification principles and help each other by holding accountability to the rules and tools of the treatment model. This assists clients with confronting and changing behaviors and poor habits by providing an environment of peer-based support. The Therapeutic Community model provides the structure necessary for those who have spent years dealing with substance use disorder to learn or re-learn responsibility, accountability and coping skills to live a healthier life and attain their long-term recovery.
The Therapeutic Community modality has been in place for over 50 years and has been well-documented by external agencies such as National Institute of Drug Abuse (NIDA) and Substance Abuse and Mental Health Services Administration (SAMHSA). Staff are considered the rational authority in this treatment model and the change agent is the community environment with their peers. Cenikor built upon this original model and added fully licensed mental health and substance use counselors in each location to treat co-occurring disorders utilizing evidence-based clinical curriculums and individualized treatment plans for each client. Recovery is a gradual, ongoing process of cognitive change and is expected it takes time for clients to advance through the stages of treatment, setting personal objectives along the way. As clients progress through the stages of recovery, they assume greater personal and social responsibilities in the community.
Cenikor takes a holistic approach to behavioral health treatment and behavior modification, including clinical treatment services, career services and education (including GED tutoring and testing as well as enrollment in college courses during this longer treatment model), family reunification and vocational services training with external business partners for our clients. Our average resident is 32 years of age with 20 years of addiction starting from age 6 through 12 with three or more treatment episodes as well as three or more encounters with the legal system. 70% of our residents are parents and 20% are females with a broad racial diversity in the communities we serve. Incarceration may have led to poor socialization and other challenges in social settings. The TC treatment modality, specifically including the vocational services aspect of the program, gives clients the opportunity to build or rebuild social skills and positive work behaviors; this supports the clients reintegrating successfully into a workplace and becoming a contributing member of society. Research has shown people who are regularly employed have lower rates of substance use compared to those who are sporadically employed or unemployed. Additionally, successful treatment outcomes (i.e., treatment completion, attaining and maintaining sobriety) are correlated with employment.
The Cenikor TC model consists of 3 distinct phases: orientation phase (21 – 60 days); primary phase (up to 18 months); and re-entry/relapse prevention phase (3-6 months). Each phase lives in a separate location within the facility. Orientation phase is set up for each new client to be introduced to the rules and tools of the TC program in a classroom setting, as well as completing initial clinical and educational assessments and receiving both individual and group therapy multiple times weekly.
Once clients transition from orientation, they enter primary phase where they receive the full scope of services including ongoing weekly clinical treatment, career services, educational services and vocational services, as well as Cenikor ensuring any medical, dental and other wellness needs are met. Primary phase is an individualized treatment program focused on modification of behaviors or habits not conducive to recovery, is self-paced and transition to the re-entry phase is based on their individual progress with all portions of the treatment program. Clients’ behaviors are addressed by the TC peer hierarchy which uses therapeutic tools to redirect to more positive habits. This may include wearing specific clothing so other clients will recognize and understand how to support their peers in being more consistent with positive behaviors and following the rules of the community. Their peers typically assign these consequences; peers use the rules and tools learned in orientation as the structure to hold each other and themselves accountable in their community, with staff providing support and oversight. By being held accountable with smaller behaviors within this structured community, clients learn how to build better boundaries for themselves for reintegration after program graduation. Learning or relearning positive social and communication skills is an integral part of building self-esteem and self-confidence necessary to make better decisions for long-term recovery. On average it costs $25,000- a year to house a client and vocational services covers about 70% with the remaining 30% coming from philanthropic giving and grants.
During the re-entry phase, each client continues their clinical and educational services and is eligible to be hired on for full-time employment with one of Cenikor’s external business partners if they so choose. Clients receive relapse prevention and financial literacy training during re-entry, begin receiving wages with this employment and reside in a separate location in the facility. Prior to graduation, each client must have a minimum of 2 months’ savings, a vehicle or other approved transportation, an external sponsor of their choosing for their recovery and have located a place to live they can financially afford. Licensed counselors are specifically assigned to re-entry clients to support the achievement of their individual employment, clinical treatment and sobriety goals. Counselors also assist re-entry clients by sharing information on banks, apartments or other community resources which will provide services or resources to Cenikor graduates in spite of criminal convictions to help ensure their success after graduation.
One of the reasons the TC model is set up in these stages is to introduce or reintroduce the concept of money management. Money is often a significant challenge in the lives of individuals with substance use disorder. Drug use and dependency directly cause money difficulties; drug habits and episodes of compulsive use of drugs can lead to uncontrolled spending. This challenge with money also reflects some of the social and psychological problems of individuals with substance use disorder. Generally, individuals with substance use disorder struggle with managing money appropriately because of a limited ability to delay gratification. Clients’ use of money in this model is carefully arranged and monitored to address their primary goals the client worked with the counselor to outline in their individual treatment plan. During primary phase, all monies received from external business partners and other philanthropic donors is utilized to pay for living quarters, transportation, food, medical, dental, clinical, educational, family reunification, general operations, client social outings and all other services provided for clients. Money is then reintroduced in the form of “walking around money” or a small stipend just prior to the re-entry phase to evaluate the way clients handle their money; how they manage this smaller amount can provide information about their overall maturity in their recovery, personal growth and readiness for re-entry/relapse prevention phase.
Vocational services training during the primary phase of treatment provides a career path for clients to be hired by companies who traditionally do not hire those with felony convictions, allowing them to return to a life of being a responsible, contributing member of society. External business partners include a diverse group of industries such as call center, manufacturing, construction, moving, pipefitting, healthcare and a variety of office support positions. Over the past 5 years, Cenikor has worked for 300+ external companies to support the work therapy component treatment for our clients. We have Career Services Managers in each location who complete career assessments during the first 30 days of treatment for each client to determine their employment interest and goals, adult education needs, as well as their current skills, abilities and any obstacles or barriers to employment. This information is used to guide the development of an Individualized Employment Plan. Career services also provide adult basic education and a skills bridge program for clients who need support in reading, math, language arts and computer skills. Additional job readiness and educational services include life skills training, assistance with applications, interviewing skills and resumes, financial literacy and other job-specific training in high demand occupations. Clients work on average 40 hours per week to ensure they have time for other services, including clinical, educational, wellness, and social outing opportunities. While Cenikor is not a specific religious-based organization, clients have the option to participate in faith-based activities of their choosing if they so desire.
Cenikor has Vocational Services Managers at each TC program who partner with our Career Services department to align external job opportunities with the client’s Individualized Employment Plan. The Vocational Services Managers also focus on workplace safety and provide training weekly to all clients in our long-term program, as well as completing weekly safety visits at external business partners work sites. This workplace safety program was developed by a Certified Occupational Safety Specialist and is reviewed on an annual basis for updates. Cenikor also works with local safety councils in each community where our long-term TC programs are located. Cenikor cannot address questions regarding specific clients, as we cannot disclose records or speak about individual clients due to federal confidentiality. Cenikor aligns with community healthcare providers to ensure all necessary medical and dental treatment is provided during their treatment program. Cenikor also provides worker’s compensation coverage for all clients in the event of injuries during the work therapy portion of their program. Because many businesses in these communities have partnered with Cenikor over several years, there are supervisors at some work locations who are Cenikor graduates and help support the success of those clients currently in treatment and completing work therapy at their location.
The goal is for a TC client to leave the program not only with their sobriety but also employed with total independence. Overall, research studies have shown TC clients show improvements in substance use, criminal behavior and mental health symptoms; Cenikor’s outcomes also align with this research. Over the past 5 years, over 500 clients have graduated from the TC program. Three years after graduation, over 75% of clients have remained actively employed, in stable living situations, and have remained law-abiding citizens. During the past 5 years, we have assisted 256 clients in receiving their GED and have had 279 clients attend college. In the past 5 years, we have served 6,417 clients in the Therapeutic Community. We have served 6,417 clients in the past 5 years. Cenikor serves approximately 80% male and 20% female clients in the long-term TC programs. Out of 10,000 clients served this year through all of our different services (short-term, detox, outpatient, TC), approximately 1,200 will be served in the TC programs.
Referrals for our programs come from a variety of sources including the state of Texas and Louisiana, judicial partner contacts such as judges and/or attorneys seeking an alternative to incarceration and other treatment programs or healthcare systems/providers such as hospitals, doctors and individual mental health practitioners. Approximately half of our clients are judicial referrals with the other half being self-referrals. We have multiple judicial partners such as Judge Ernest White who believe certain individuals who are facing criminal charges should have an option of electing treatment programs that focuses on treating substance use disorder and behavioral health as an alternative to incarceration.
In addition to being regulated by HHSC, Cenikor is a CARF certified organization (Commission on Accreditation of Rehabilitation Facilities), is an accredited charity with the Better Business Bureau, and has received a 4-star rating on Charity Navigator for the past 10 years, placing Cenikor in the top 5% of all non-profits rated by Charity Navigator. These are external, independent agencies responsible for auditing Cenikor’s services, processes and/or financial practices. As to specific questions regarding the Department of Labor remarks, we cannot comment on what was stated because we do not know the context of their remarks. Cenikor complies with all applicable federal and state labor laws.
Cenikor Foundation believes this holistic approach and individual treatment for each client gives the best opportunity to build or rebuild the skills needed to obtain and maintain long-term recovery, maintain successful family and personal relationships and return to being a contributing member of society.
De Leon, G. (2000). The Therapeutic Community. New York, NY: Springer Publishing Company.
Texas Administrative Code. (2004, September 10). Retrieved April 18, 2019, from https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=448&rl=1401
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