Over the years that I have worked as a psychologist, I became more and more aware of a subgroup of our society that has been looked down upon as disreputable and untrustworthy persons who are freeloaders in our social system and resistant to changing for the better. They have been typically described as morally impoverished, uneducated and unemployed drug abusers or alcoholics, who might also be homeless and living under bridges or in the hallways of our communities. These are also the people who the mental health professions tended to avoid as treatment resistant personality disordered individuals who not only are extremely unreliable for becoming involved in or following through with treatment, but are also individuals who have extremely negative prognoses for success.
Historically, the mental health professions avoided or ignored them, leaving them to being handled by legal systems and jails and/or human service systems such as child protection, probation, and welfare. When arrested for drug or alcohol abuse violations, they may at times have been sent to chemical dependency treatment programs, but the success of those programs for instilling prolonged abstinence in their patients were no better than chance or even worse.
The situation went on until a psychologist from the University of Washington by the name of Marsha Linehan developed a therapeutic procedure for the treatment of people with borderline personality disorders, persons that up to that time were considered virtually untreatable and were highly representative of the subgroup of people referred to here. She called her program Dialectical Behavioral Therapy, or DBT for short. Her innovative work did two things. First, it underscored the fact that people with resistant personality disorders can be treated successfully. Secondly, it successfully countered the developing trend in treatment towards “brief therapy”, or reduced therapeutic sessions for all disorders, inspired by insurers and governmental organizations who were driven by the primary goal of cutting costs and by an ignorance or disregard of human behavior.
DBT not only gave encouragement to mental health professionals to become more seriously involved in the treatment of this previously avoided subgroup of society, but it also underscored the fact that many patients would require up to two or more years of continuous treatment in order to overcome their lifelong problems. Since Linehan rolled out the DBT program, many mental health professionals have been trained in using it, and have used it to varying degrees of success with otherwise hard to treat individuals.
Despite Linehan’s contribution to therapy, the complete therapeutic needs of this social subgroup have not yet been properly met. That is, they continue to be sent to chemical dependency treatment where the primary training and focus is on addictions and recovery, with superficial therapeutic services being given to other mental health issues, even when the programs describe themselves as co-occurring treatment programs. The same individuals may be sent through DBT, CBT or other effective psychotherapeutic treatment, but that is not done as part of a coordinated treatment effort and may occur at a different time under circumstances not compatible with any other treatment they may have undergone.
Although Linehan’s program was designed to effectively treat personality disordered individuals, a comprehensive understanding of their psychological and emotional makeup’s did not occur until a movement of psychologists and psychiatrists, involved in working with such individuals, developed a new diagnostic category which they labeled Complex Posttraumatic Stress Disorder (CPTSD). They also developed the diagnosis of Developmental Trauma Disorder (DTD) to describe the effects of traumatic environments and upbringing on individuals and to supplement the more comprehensive description of symptoms and disorders comprising CPTSD. This therapeutic movement has contributed significantly to the understanding and more effective treatment of the social subgroup being discussed here.
Despite all of this progress, a comprehensive treatment model that works effectively has not yet been established. Worse yet, regardless of what treatment they receive, almost all of these individuals are left in or returned to their debilitating environments, in substandard housing and in neighborhoods with the individuals who very likely contributed to their inappropriate lifestyles and behaviors. As people from this subgroup enter the system, more demands are placed by them by the various county or state case managers or probation or other agents who have acquired responsibilities for affecting their lives. No concern is given to their basic needs for transportation when they have no vehicles or driver’s licenses, or childcare when they have no money or support persons to watch over their children. The combination of greater demands on these individuals with no assistance in terms of their needs has proven to be the most effective factor in their eventual failures to succeed and their relapse within the legal or social systems in which they eventually become perennial members.
My work with this population of troubled people started in full bloom when I agreed to examine and diagnose patients of a residential chemical dependency treatment facility and then to develop a psychological program to assist in treating the psychological needs of those residents. It became very clear to me that almost all of the patients had complex psychological disorders that included disturbed thinking processes, distressed and uncontrolled emotional reactions, and lifelong learned inappropriate behavioral styles. They required a significant amount of psychotherapeutic intervention and ongoing assistance after being discharged from the treatment facility. I found that such treatment could have a positive effect on the patients, but I also observed that when they eventually returned to their home communities the negative effects of their environments and housing conditions, as well as their lack of support and money, eventually broke down whatever positive steps they made and caused them to fail. I also found that the outpatient agencies charged with continuing their care and treatment actually seemed to contribute more to their failures because of the added stresses they placed on the patients.
This is what led to my conceptualization and development of a model of what I believe is the next needed step in assuring the effective treatment and change for individuals from this social subgroup. It has as a foundation Maslow’s hierarchical concept for human development which indicates that a person cannot attend to their psychological, social or self-actualization needs until their basic needs for safety and security are provided for. Proper housing, food and clothing, as well as safe living conditions are essential before any kind of therapy can be effective for an individual or his or her family. But, just adding on additional supervisory, educational, or treatment services without integrating everything into a comprehensive plan is not enough. Furthermore, treatment or care providers or agencies that may have independent treatment or outcome goals are often counterproductive when they are charged with providing services to the same individual, and they are likely to contribute to failure rather than success.
My therapeutic concept is designed for people who suffer from a complexity of disorders, including psychological, medical, and addictive, that mostly typically fit the multiple symptoms described by the Complex PTSD diagnosis. Their disorders have a developmental origin, often in abusive, under-attended and traumatic living conditions from birth or early childhood to early adulthood and afterward, and their personality styles reflect the inadequate or self-defeating traits resulting from such lifestyles. Because they have poor self-control systems and even more deficient parenting skills, these individuals tend to perpetuate the same kinds of problems from generation to generation.
My theraputic model requires that the patient and her family are able to have a permanent residence where they have an adequate and fit living space (an apartment), a safe environment ensured by secured and supervised entry and exit points, and a healthy environment in which living facility and personal hygiene, positive social interactions and individual and family enrichment are embedded and accentuated. In addition it provides, within the living facility, medical and psychological services for the patients and their families in ways that do not place undue stresses on the individuals. These services are integrated, with one master treatment plan for each family and/or their individual members, and all treatment is provided by a treatment team with specialists who are responsible for working together to support and complete the treatment goals. This team will stay with the patient and/or family as long as needed so that therapeutic bonds and continuity are preserved and treatment goals are reached.
At this point in my professional career, it is my observation and belief that a true therapeutic model for significant cognitive and behavior changes in individuals has to be a comprehensive program in which shelter, safety, nurturance, and therapy are all part of one package. Therapy alone, or care/supervision interventions, are not adequate enough to overcome the forces of one’s living conditions. And, living conditions must be altered significantly from traditional housing and management ways to support the therapeutic process. And these change conditions can only be effective when they become integrated in one therapeutic program.
This is the vision for the Solace Project, which has recently been funded for a 30 unit residential facility in St. Peter Minnesota where individuals from the social subgroup being discussed here will become residents along with family members. Most will likely meet criteria for homelessness, indigence, and some levels of severe and persistent mental illnesses. They may come from chemical dependency or co-occurring treatment programs, or by referral from drug courts, penal institutions, transient housing programs, or County systems. They will very likely be persons with damaged psychological conditions and faulty or inadequate coping systems, and will require comprehensive and long term therapeutic intervention within a supportive therapeutic living environment that provides permanent housing to them and their families.
If this comprehensive, integrated therapeutic system can be instituted without change or degradation, these individuals will finally get a fair chance at changing for the better and becoming effective self-supporting citizens of our society.