Keywords: Therapeutic Community, educator, psychoactive substance use

Abstract

Systematization axis: The experience in the therapeutic community was systematized having as its axis, the reconstruction and critical interpretation of the role of the educator in the treatment of adults with disorders due to the use of psychoactive substances of the Cenicsol residential program. The objective is to critically evaluate the educator’s role in the therapeutic community and community and treatment. Method: The methodology used to systematize experiences of five main moments: the starting point; the initial questions; recovery of the process experienced; the background reflection and finally the arrival points. The instruments applied were the semi-structured interview. The therapeutic director, two therapists, three educators, and three users from the adult therapeutic community were interviewed. Results: The therapeutic community is a drug-free residential environment, it is a highly structured system whose fundamental characteristic is the existence of an artificial pressure system, which obeys the fundamental purpose which is to activate the pathology of the addict in treatment and promote social rehabilitation. The educator is a facilitator of the user’s recovery process, coordinates programmed activities of the community, and performs therapeutic interventions if necessary. Among the main therapeutic strategies are empathic listening and observation, using cognitive-behavior and group counseling.

Introduction

Substance use disorders are characterized by a maladaptive pattern of drug use that leads to clinically significant deterioration or discomfort, accompanied by phenomena such as tolerance and abstinence (APA, 2014; WHO, 2004; UNCDF, 2017). The subject comes to act motivated mainly by consumption, affecting all dimensions of their life (personal, family, social, work) being unable to function effectively in society (UNDC, 2017; Caballo et al., 2014). Due to the prevailing need to treat and prevent the consumption of psychoactive substances, various models of addiction treatment have been designed, among these, one of the most developed internationally is the therapeutic community methodology (NIDA, 2012; UNDC, 2017), employed at the Nicaraguan Solidarity Center (Cenicsol), with nationwide coverage of the problem of addictions.

A therapeutic community is a residential addiction treatment program based on the concept of self-help, the group and a complex system of educational activities, time occupation and organization that constitutes a global educational-therapeutic system, the main therapist,agent of change and role model is the community itself formed by the users and the therapeutic team, the members of the therapeutic community interact in structured and unstructured ways to influence the attitudes, perceptions and behaviors associated with drug use (UNCDF, 2017).

One of the fundamental actors in the therapeutic community is the educator, who has a direct and helpful educational relationship with the user, assists him in the process of resocialization and social reintegration (UNDC, 2017). It intervenes in the daily life of the community as an intermediary in relationships, conflict resolution and decision-making, based on a proper social life inside and outside the community.

The experience in the therapeutic community was systemtized with the reconstruction and critical interpretation of the educator role in the treatment of adults with psychoactive substance use disorders of the Cenicsol residential program, while the general objective is to develop a critical evaluation of the role of the educator in the therapeutic community and treatment.

Development

Method

The methodology was used to systematize experiences of Jara (1998; 2012), which consists of carrying out a process of reflection to organize processes and results of a project, in order to explain the course that assumed the work done. As the experience involves various actors, the systematization tries to understand the meaning that the process has had for the participants in it. All this through five main moments: the starting point; the initial questions; recovery of the lived process; the background reflection and finally the points of arrival.

The starting point: For the realization of a systematization a practice must preceded. The experience of educators in the adult therapeutic community of Cenicsol is the object of systematization.

Establish initial questions: For this systematization the following questions have been formulated: What is the methodology of the therapeutic community? What is the role of the educator in the therapeutic community? What is the importance of the educator in the therapeutic community? What difficulties or limitations does the educator face in the therapeutic community? How could the educator’s work in the therapeutic community be improved?

Reconstruction of the experience: In a third moment we try to reconstruct the history and classify and organize the information, looking for a global and objective vision of the phenomenon. The instrument applied was a semi-structured interview, designed from the axis and objective of systematization. Interviews were conducted with Cenicsol staff working in the adult community. The therapeutic director was interviewed; two therapists; the three educators of the adult therapeutic community, as the main protagonists of the practice (Table 1).

Table 1.

Cenicsol staff interviewed.

Three users living in the adult community, who work directly with the educator in daily living, were interviewed (Table 2).

Table 2.

Cenicsol users interviewed.

The axis of systematization gave guidelines to order and classify the information, for this task the list of initial questions that allows to articulate the work and the elaboration of analysis matrices to be able to identify the different perceptions of the actors involved in the experience was useful. Once the information was ordered and classified, the triangulation was carried out, which consisted of comparing the different perceptions of the different actors involved about the experience of the educator within the therapeutic community.

Make a fundamental reflection: This is a key moment in the process of systematization, it is an analysis, synthesis and critical interpretation of the lived process, of transcending the descriptive limits and abstracting the reason for what happened in the process of experience. The key question right now is: Why did that happened?

Points of arrival: At this stage the learnings and conclusions of the experience are concreted and communicated. Here we reconstruct the lessons learned throughout this practice.

Results of the experience

The therapeutic community

The methodology of therapeutic community has as a fundamental characteristic, the existence of an artificial pressure system, which obeys a fundamental purpose to activate the pathology of the addict in treatment, that pressure is voluntarily tolerated by the resident which means that he is completely free to decide whether or not to tolerate that pressure system (UNODC, 2017).

According to the therapeutic director of Cenicsol, the characteristics of a therapeutic community are the “psychosocial, spiritual character, and from that micro-social environment, promote the social rehabilitation of the addict based on a humanistic, cognitive behavioral and logotherapeutic approach”, the community then encompasses an eclectic and holistic intervention model in the treatment of addictions, considering the user as a bio-psycho-social unit.

Through a multidisciplinary approach, it promotes the relationship between equals, dignified treatment, individual and group intervention, self-care and personal growth. It emphasizes the comprehensive treatment of addictions taking into account users and family members, and has as its final objective the socio-labor reintegration. (therapist 2)

The community seeks that the user is an active agent of his own change, of his transformation and re-education, to integrate into a demanding and exclusive society before those individuals unable to function according to group norms.

For their part, the therapists of this center argue that the therapeutic community is an open environment free of drugs, characterized by human coexistence, between users and therapists, social reintegration implies a self-discovery by the user, of his Self, of his real living conditions, of his weaknesses and strengths, of his opportunities, of his risk factors, eliminating the cognitive distortions characteristic of addictive thinking.

One of the therapists states that “a methodology focused on the cognitive behavioral part, which is carried out in daily living and in individual interventions, in therapies, in the workplace, it is about modifying thoughts, feelings, and automating behaviors” (therapist 1). It is observed that there is awareness of the objective of the community on the part of the team members and users.

As for the methodology of the center as a therapeutic community, the therapeutic principle is “care and personal growth, reestablish personal principles and values, promoting in each user a spiritual awakening” (therapist 2), which is complemented by “learning to respect the human being, learning to communicate, interact, decide in a group, take care of himself and the environment, and learn to value cultural and academic knowledge” (therapist 1), the entire therapeutic process is about learning, internalization and assimilation of healthy thoughts, values and behaviors that humanize the user, and make him an effective and efficient member of society.

According to the director, if therapeutic tools are used properly, they have a great impact on the user’s consciousness, directing them to a greater degree of reflection regarding their life and the historical-social conditionings that have influenced their development, as well as the generation of short- and long-term goals, and the behaviors necessary to achieve these goals. The main therapeutic tool is that “each of the therapists can apply the following elements: confrontation, signaling, verbal reprimand, personal reprimand, rethinking, temporary and definitive expulsions, community interventions, seminars, educational experiences, reflections, life history and group therapy” (therapist 2).

According to the therapeutic director, the therapeutic process:

It is based on the daily life that tries to cover all areas of our life: morning, personal hygiene, work sectors, meeting, life history, weekend group, social skills, self-esteem group, growth group, school for parents, recreational activities, seminars, technical courses. (therapist 2).

For his part, one of the therapists interviewed defines that the therapeutic stages are”the stage of observation, reception, motivation, identification, elaboration, consolidation and reintegration” (therapist 1). The community is a highly structured system, each moment is designed with a therapeutic objective, in order to return to the user a structure in his life, temporal spatial orientation, individual and group awareness of the disease and acceptance of the concept and practice of self-help. It is considered that the user of the community is an active and purposeful agent, responsible for their own process of personal growth and social rehabilitation, is one of the main actors in the process of change, since only they can be managers of their own change.

Educator experience

The role of the educator in the therapeutic community is essential for its proper functioning, with quality and therapeutic intensity. Among the functions they are to watch over the community at the time when the therapeutic team is not found, in addition to making containment and maintaining the rhythm and therapeutic intensity of the work that is done in the day, this is one of the most important functions, since when the educator receives a shift, it is transmitted through a report, the diagnosis of how the community is and the measures to be followed during the night shift, exercising a therapeutic continuity.

According to the therapists interviewed, “the educator maintains the balance and intensity of the therapeutic work in a more relaxed environment, which allows the educator to be a direct observer of the behaviors of the users naturally” (therapist 2), which constitutes fundamental information to design strategies and plans for individual and group intervention. The educator, “is a facilitator of the user’s recovery process, since he coordinates activities planned in the shifts that are assigned to him observing the behavior of the community while interacting with it, in addition to making therapeutic interventions” (therapist 1).

On the other hand, educators consider that their main functions are to respect the daily life of the community, as well as to give therapeutic continuity to the work that is carried out with each user, either with advice on assigned therapeutic activities, observe the moods in the closing groups and provide feedback, integrate into recreational activities, and one of the most important is therapeutic intervention on relevant occasions, according to the needs of the community.

An educator comments that among his functions in relation to daily life are “to ensure that there is an order, to supervise the sectors of work, delivery of tobacco, of medicines, to carry out a group at night, that the community operates under the rules, to wake up in the morning to the users for the morning” (educator 1).

In the words of an educator, his goal is “to integrate into the community, to be a facilitator of the process, to make see inappropriate behaviors to modify them, to solve the problems that arise in daily life and to be a model of behavior for users”(educator 3), which implies a high level of integration in the community with a share of power and responsibility to direct the community towards the general therapeutic objectives.

The users of the center also have a certain perception about the functions of this community agent. The user comments that the educator is “a counselor in difficult moments, when I felt shot I went to the educator for help ... is someone who can help me in moments of crisis during my process, an emotional point at night” (user 1). Due to the nature of his role in the community, the educator is seen as an integrated agent in the psychosocial dynamics, he is someone who lives the community, according to an interviewed user, perceives the educator “as a friend in whom I can trust, shares moments of recreation, sports, is the guide of the community” (user1), reflecting a high level of therapeutic and psychoeducational connection.

Some of the experiences narrated by users indicate the level of integration of the educator with the community in general and with individual therapeutic processes in a specific way: “Every time I have problems and you hear me about my illness, it makes me feel like a better person and I look at things from another perspective” (user 2); “The educator has helped me a lot in assigned jobs, once I felt sad, worried and wanting to consume, I talked to the educator and my mind was cleared, motivated to continue working on the process” (user 3); “Three months after being in the community, an uncle of mine died, the educator along with the rest of the staff helped me to carry that grief, that meant a lot, they helped me to work my grief” (user 1)

In the exercise of his functions within the community, the educator makes use of various techniques and therapeutic strategies to contribute to the re-education of the user. Among the main therapeutic strategies are the management of certain aspects of the life history of users to be able to perform therapeutic interventions, empathic listening and observation, to perform a quality therapeutic approach, also uses cognitive behavioral techniques in counseling. One educator shares that in his experience within the community “apart from confrontation and signaling, empathic listening, cognitive behavioral feedback, counseling, re-education from the position of a sympathetic parent” is also used (educator 3).

For many users, the educator is one more within the community, serving as a guide within their process, the user engages empathy with it according to their personality. One of the users comments on the following:

Each educator has his methodology, his way of being, in general there is a good relationship between the educator and users, it is a relationship framed in respect ... I get along excellent, I thank the educator very much, they have been the beacon that has guided me through difficult paths with their attention and advice that will last until I die, the risk factors will always be, but remembering the advice they gave me are a stop to not fall into alcohol. (user 1)

Critical reflection on the experience

The work of the educator is central to the proper functioning of the therapeutic community, all the members of this agree on the great importance it has to guarantee the therapeutic quality and the integrality of the process.

The director of the center has an assessment of the role of the educator depending on the person who occupies the position, comments that the evaluation that can make of this agent of the community has “very positive aspects such as the participation of an educator who is involved so much that he does more than his role determines and provide service with human warmth, feedback to the therapeutic team” (therapist 2), this indicates that the involvement by the educator in the daily life of the community is a very important factor when making an evaluation, which reflects commitment, identification and satisfaction with the work done.

However, the director continues, there are other cases “that after being in three years in the therapeutic community generate a feeling of frustration and discontent for the little involvement, providing undignified and inhuman treatment, for not knowing how to manage tolerance and frustration” (therapist 2). This assessment reflects the dissatisfaction that exists with the work of some educators with little commitment and work motivation (an aspect that is beyond the scope of this systematization, but that are interesting topics to consider in another opportunity for reflection and analysis), which affects therapeutic work and the development of the community as a whole. Another particular case mentioned by the therapeutic director is that “other[educators] see the community from the outside, and others because it is perceived that their vocational interests are not those of being an educator, but that they do a good job fulfilling their work for paid interests” (therapist 2).

The assessment of the educator is made not according to the job, but to the people who fulfill this role within the community, which have personality characteristics, values, motivations, interests, training, skills and different knowledge, which affects the continuity and uniformity of the therapeutic work, as well as perceptions, opinions and different attitudes about the educator.

In relation to the limiting factors that the educator has in the exercise of his functions, again the director of the center emphasizes “that not all educators have tolerance to frustration, teamwork capacity, lack of involvement in recreational and recreational activities, lack of organization to handle drugs, be aware of the calls they receive” (therapist2). However, there are difficulties that are not only the direct responsibility of the educator, but also of the conditions provided by the center, as indicated by the director, “there is no nurse or doctor on the ground for cases with dual disorders or medical emergencies, in addition there is no substitute educator who can replace in an emergency situation” (therapist 2).

Educators also express various difficulties they encounter in the performance of their duties, for example, they consider it a limitation to “consult with therapists before making a decision, for example, in case of an emergency, phone calls, be aware of educational experiences during weekends” (educator 2), this has a direct impact on the attention of users, by compromising the fluidity of treatment and control of the community as a system. On the other hand, one of the educators states that a limitation “can often be the training of the educator, the lack of insight or empathy, not committing to the community, also the lack of material resources, for example, a vehicle to move in case of an emergency” (educator 3), which can be reflected in the quality and relevance of the therapeutic interventions carried out. In summary, there are limitations in terms of physical resources, therapeutic training and communication with the work team, which hinders the functioning of the community as a fully integrated system.

As for its value, it is considered that the work of the educator is “important because at night the community has another behavior, must realize what the night means and each day of the week, must have the knowledge and insight to interpret the user in the daily life” (therapist 1). One of the educators maintains that the work “has a therapeutic value, because sometimes with the educator he has more confidence than with the therapist, and thus the information and the work is complemented” (educator 3).

The importance of the educator is reflected in the words of a Cenicsol user:

As addicts we have many street behaviors, without the educator the community would be an anarchy, you have to be sensitive, subtle and firm to manage the community. If it weren’t for the educator I wasn’t here, I wouldn’t have had the opportunity to know myself, now I’m about to leave, in the process of reconciling with my family and starting work, the educator has been very important in my process. (user 1)

Finally it is considered that the educator has to “fit into the dynamics of the whole community, in the methodology, must reinforce the work that is done in the community, attend to the user, the educator has his place, is a reinforcement in the community” (therapist 1). For the effective fulfillment of his functions, the educator must fulfill a series of characteristics, for the director of the center, this “has to be a mental health professional with charisma, disposition and human and vocational quality, responsibility and respect, attitude of service, needs empathy, good interpersonal relations, ability to work in a team, management capacity, disposition” (therapist 2).

The educators of the center also consider a series of qualities and personal characteristics necessary to be able to contribute to the community through their work, the educator must be "patient, tolerant, assertive, have tact in the fulfillment of their work, have their ability to listen, and have the ability to make correct decisions” (Educator 1). It must practice “Tolerance, persuasiveness, security, professionalism, awareness of the role as an educator, it has to be a model of learning behaviors for the user” (educator 2). Finally they consider that the person “Has to be humble and respectful to users." (educator 3).

With the work in therapeutic community, each agent involved in the process of user change has had significant and enriching experiences through daily life in the community, an experience that has left important lessons learned for all members of the community, individually and collectively.

One of the educators shares that it has been important “to be able to give back what I was once given as a user, improve the use of therapeutic tools, be more effective in decision-making and make fewer mistakes” (educator 1). Another educator appreciates that “my experience I value as positive because as cases are attended to, I have learned to teach, listen, intervene to the addicted patient and manage their behavior.” (educator 2). Finally, the last of the educators expresses that “the experience has been one of continuous learning, feeling part of a whole as an agent of change, the most important lesson is that the disease of addiction can be developed by any human being, turning living into an art” (educator 3).

Proposals that optimize the work of the educator

To contribute to the development of the therapeutic community from the perspective of the educator, different actors propose strategies that optimize the work done. The director of Cenicsol proposes that the educator has to “love what he does, prioritize his life commitment, get involved and assume his role as an educator” (therapist 2), which indicates that he has to have a real commitment and involvement in the community, which guarantees a positive and significant impact on the therapeutic process of the users. As for the educators, for a better fulfillment of their functions they propose “to know more deeply the process of each user ... participate in therapeutic interventions, directly influence activities oriented in daily life... maintain an attitude of continuous learning also update on intervention strategies” (educator 3).

Conclusions

The therapeutic community is a residential environment free of drugs, it has as a fundamental characteristic, the existence of an artificial pressure system, which obeys the fundamental purpose which is to activate the pathology of the addict in treatment and promote social rehabilitation. It is a highly structured system, each moment of daily living is designed with a therapeutic objective, in order to return to the user a structure in his life, temporal space orientation, individual and group awareness of the disease. The community considers and seeks that the user is an active agent of their own change to integrate into society.

The role of the educator in the therapeutic community is essential for its proper functioning. It ensures the community at a time when the therapeutic equipment is not found, in addition to making containment and maintaining the rhythm and therapeutic intensity of the work. It is a facilitator of the user’s recovery process, since it coordinates activities planned in the shifts that are assigned to it observing the behavior of the community while interacting with it, in addition to making therapeutic interventions if necessary. Among the main therapeutic strategies are the management of certain aspects of the life history of users, empathic listening and observation, using cognitive behavioral techniques in individual and group counseling. In the reflection of the work done by the educator there are very positive aspects such as the participation of an educator so much that he does more than his role determines, such as direct attention to users, accompaniment in crisis, and providing service with human warmth and feedback to the therapeutic team. There are other cases of educators who have little involvement, with little ability to handle frustration, transference and countertransference. In general terms, the work of the educator is important as agents of change in the therapeutic process of the user, developing the bases for a self-sustainable social reintegration.

For the effective fulfillment of their functions, the educator must meet a series of characteristics, this has to be a mental health professional with adequate preparation, charisma, disposition, human and vocational quality, responsibility and respect, attitude of service, empathy, good interpersonal relations and teamwork.