The Therapeutic Community and the Medical Model.

Martien Kooyman, M.D. , Ph.D.

Introduction
The philosophy of the original therapeutic communities for addicted persons is based on selfhelp and mutual help. The residents in a therapeutic community learn to help themselves with
the help of their peers. In the early American therapeutic communities for drug addicts which
used this concept, the staff consisted almost entirely of recovered addicts, often graduates of
the same programs.
In Europe, most therapeutic communities had been founded by professionals using the
American therapeutic communities as a model. They started with a staff consisting of social
workers, doctors, art therapists, occupational therapists, teachers, nurses, psychologists and
psychiatrists. They later added recovered addicts to their staff. The leaders were usually
psychiatrists or psychologists. The professionals had to unlearn helping their clients and to
learn teaching them to help themselves. The recovered addicts in Europe had to follow a
training to become a professional group worker and to learn to speak the language of the
professionals. In both groups one could see a fear to be incompetent for the role as staff
member in the therapeutic community (Kooyman, 2002).
Many professionals in the European therapeutic communities started to introduce specific
therapies in the Therapeutic communities, often they did so to overcome their feelings of
insecurity or their need to be a therapist. In itself these specific therapy methods can be an
asset to the therapeutic community. However they should be integrated well in the self help
philosophy. Several therapeutic communities in Europe have become institutions with the
staff providing therapy, instead of a system where the resident can learn by experience with
the help of role models. This is in conflict with the original philosophy. Some therapeutic
communities in the Netherlands, that were originally medical model hospitals, have been
changed again into medical model clinics in the Nineties.
In the past, addiction to opiates was treated with the prescription of heroin. Addiction to
heroin was treated with the prescription of methadone.
Nowadays professionals call addiction a chronic relapsing disease and describe similarities
with diabetes and asthma (McLellan, c.s., 2005). Lifelong substitution with methadone is
recommended. In the Netherlands methadone, together with heroin, is distributed to persons
addicted to methadone and heroin without providing any further treatment.
Is addiction a chronic relapsing disease?
Is addiction a disease?
Many doctors are now calling addiction a disease and seek for a medical solution of the
addiction problem. The term disease fits in the medical model. A disease needs treatment:
They do not realize, that the medical profession has been better at creating addictions than
inventing a cure for them. Medication to diminish craving has so far not shown any
considerable results.
Although addiction is often regarded as a disease, addiction is as much a disease as fever or
high blood pressure or blindness, although persons suffering from these conditions, that may
have various causes, can be regarded as being ill.
For some persons the substance they use is just one of many things making them feel better. It
can help to no longer feel the fear and pain of daily life.

Addiction in my opinion can be regarded as an adjustment to exceptional circumstances by

means of adaptive behaviour that has become uncontrollable. Addiction can arise when
control over this behaviour is lost.
When a person has become addicted he is caught in a vicious circle:" I drink because my wife
is angry at me because I drink".
He is caught up in several vicious circles (van Dijk, 1971) : a pharmacological vicious circle
(stopping produces effects which force him to use again), a psychological vicious circle
(stopping no longer hides negative thoughts or feelings such as guilt feelings which make a
person use again), the vicious circle of the primary group (the friends: peers still addicted,
reject a person that stops using, or the family: the addict helps the parents to stay together by
being the scapegoat, presenting a problem for them, making it difficult to stop) and the
vicious circle of society (the ex-addict is not trusted: " once an addict always an addict".
See Figure 1.

Treatment with abstinence as a goal has to be directed at breaking down all four circles.
Addiction can be better named a disorder instead of a disease, usually being a symptom of an
underlying problem. Addiction is a self-inflicted disorder with multiple causes (Kooyman,
2007).
The definition of addiction
The definition of addiction which follows from this is :
Addiction is a self- continuing harmful process resulting from the loss of control over
adaptive behaviour which then itself becomes a problem. (Kooyman, 1992 pp. 223).
Is addiction chronic?
The Dutch psychologist Prof. Gerard Schippers concluded in a study of 5 reviews based on 56
original studies with data of more than 30.000 drug abusers ( including the DARP and TOPS

follow-up data) that, although there is a slow increase in the number of deaths ( ca. 20% after
20 years, there is also a steadily growing number of abstainers ( 40% after 10 to 20 years). In
contrast with the maturing out theory, the percentages of abstainers, abusers and nonproblematic users tend to stabilize in the 10-20 year follow-up figures (Schippers, 2006).
These studies were on ex-clients of drug treatment programs.
See Figure 2.

Long term drug use

( excl. unknown )
100
90
80
70
60
50
40
30
20
10
0
start

20%

Deceased

20%

Problem use
20%

Integrated use
40%

Abstinent
5 year
follow-up

10 year
15 year
follow-up follow-up

20 year
follow-up
Cramer & Schippers, 1994

In contrast with the maturing out theory, the percentages of abstainers, abusers and nonproblematic users tend to stabilize in the 10-20 year follow-up figures (Cramer and Schippers,
1994).
The studies were on ex-clients of treatment programs.
For alcohol, there are also studies in the general population.
In a review of 870 references, Schippers found in longitudinal studies that persons in the
general population diagnosed with alcohol dependence were no longer diagnosed as alcohol
dependent three or more years later in 17-26% of the cases. In the clinical populations, these
percentages were: 35-52%. This difference can be explained by the finding that alcohol
dependent persons seeking treatment seem to differ in severity from the alcoholics not seeking
treatment. (De Bruijn, 2005). It also can indicate that treatment helps to no longer be
dependent on alcohol.
Schippers concluded that of the people with alcohol dependency entering treatment for their
alcohol problems, 60% are no longer in that condition several years later.
This percentage is considerably higher than the 39% recovery rate of psychiatric disorders
recorded in the literature (Schippers 2006).
These findings show that chronic addiction is less common than often assumed.
Is addiction a relapsing condition?
In the review of alcohol studies, it was found that the hazard of relapse was higher in the first
4 years than after that period ( Schippers, 2006). The longer the person abstains the less likely
there will be a relapse.

This was also found in the follow-up study of all first admissions of the Emiliehoeve TC.
After two years since leaving the program 49 % of the ex-clients had never used any drug and
neither had any abuse of alcohol during the six moths preceding the interview. However some
of them had relapsed for a short period after they had left the program; 32% had had no
relapse since leaving the program (even using or instance cocaine once was regarded as a
relapse).
After 2 years and 9 months, this percentage was 24%. After 5 years since they had left the
programme, 21% had never a relapse. (Kooyman, 1992, 1993). The majority of these relapses
had not been abuse of the main drug that they had been addicted to before their treatment,
such as heroin or amphetamines, but the abuse of alcohol, cannabis, tranquillizers or sleeping
pills.
Harriet Barr found in a seven- year follow up of ex- residents, including all drop-outs of the
Eagleville TC in Philadelphia, that over time more persons in this follow up remained clean
without relapses. (Barr c.s., 1980).
Therefore, we can say that a relapse does not have to occur when a person is abstinent after
having been addicted to drugs and that the longer a person is abstinent the less likely he is
relapsing.
If addiction is not a chronic relapsing disease, what then is addiction?
It is important to make a distinction between (non problematic use) and addiction. Not every
person using alcohol becomes addicted. Not everyone using drugs becomes a drug addict.
There must be something else within the person or in his environment which leads to
addiction.
Some persons are apparently more vulnerable than others are to become addicted. Some
persons may have a genetic constitution making them more vulnerable. Some persons live in
circumstances whereby there is a high risk of becoming addicted.
The term chronic relapsing disease it offers an excuse when treatment fails.
To call addiction a chronic relapsing disease has to be avoided as it causes unnecessary
pessimism and a lack of motivation for treatment among primary care physicians (De Bruijn
c.s.20005). It can become a negative self-fulfilling prophesy.
Addiction is a condition caused by something else, usually a combination of different factors.
The name: chronic relapsing disease is not only incorrect, it ignores facts that are in
contradiction with this name, such as the long lasting positive successes of drug free
treatment.
Addiction is a condition caused by something else, usually a combination of different factors.
Hereditary factors
In the medical field nowadays, much interest is paid to research on hereditary and
neurobiological factors in addition. There is evidence that there is a hereditary vulnerability.
The heritability to respond to the use of alcohol with alcoholism has been estimated at 40-60
percent. It appears that hereditary factors do apply in alcohol as well as in drug dependence
(De Jong, c.s., 2006). Twin studies also indicated a cross-inheritance for anti-social
personality and alcoholism.(Enoch, 2003)
Pharmacological factors

The drug itself may cause changes in the body. To reach the same effect higher dosages may
be needed. Withdrawal symptoms may cause a need to use again. Opiates can replace
endorphins at the receptors in the brain. When the opiates are no longer administered, they
can not be replaced by endorphines, which have not been sufficiently produced in the body,
leading to abstinence symptoms. These symptoms can be alleviated by using again.
Drugs and alcohol can as well as medicines reduce symptoms caused by mental disorders.
Addiction can start as self-medication. However, a developing dependence can become a
problem in itself.
Psychological factors
There are common psychological characteristics of the addicted person.
Drug addicts have a failure identity and are unable to sustain long lasting relationships.
Drugs can be used to relieve stress and painful emotions. Rejection in early childhood is a
painful experience. It can lead to unsafe attachment and the development of a negative selfimage. If the child does not feel love and affection from the parents, the child feels rejected
and then starts believing: I am bad. But not knowing the reason why is unbearable, so the
child starts to be naughty and develops a negative self image. Of course my parents do not
love me. The acting out behaviour can lead to stealing and using drugs. In a research on
heroin addicts in The Netherlands, it was found that half of the addicts had already been in
contact with the police for offences before they used their first drug (Jansen and Swierstra,
1983).
The
distrust in one self and others of the adolescent can result in a low self esteem and fear of
rejection. Leaving the family of origin and leaving home becomes problematic. This may well
be an explanation why addiction often develops in adolescence. We know from research that
drug addicts have more frequent contact with their parents than persons of the same age who
are not addicted.
Not being able to deal with guilt feelings and the painful emotions of being rejected can lead
to substance abuse and addiction (Kooyman, 1992).
Addicted persons are unable to ask for help and deny their addiction out of fear of rejection.
Manipulative behaviour, which develops in early childhood, serves in particular to avoid
possible rejection. (Kooyman, 1986 ). Most addicts have a fear of closeness and intimacy
related to this fear of rejection.
Traumas.
Traumatic experiences are often present in the history of addicted persons. Traumas in youth
such as physical and sexual abuse, incest and separation from the parents apparently makes
young people more vulnerable to drug addiction. More than half of the female residents in
therapeutic communities were victims of incest or sexual abuse in their childhood.
It has been shown in animal experiments that traumatised animals are more vulnerable to
become addicted to alcohol and drugs. There is some evidence experiments with monkeys
that early deprivation by separation from the mother does not only produce psychological
effects but also biological and physiological traumas, making the young animal more
vulnerable to addiction. This may well also be the case in young children. Van der Kolk
(1992) stated, that early traumatisation by parent leads to a negative bonding.

Although insufficient research has been carried out to support the hypothesis that traumatic
experiences in early childhood make someone especially vulnerable to becoming addicted at a
later age, there are many indications to support this. It seems probable that a lack of affection
and tenderness in early childhood is traumatic and causes the child to be more vulnerable to
the pain of a rejection by others. The more often an individual felt rejected as a child, the
more painful the experience becomes. It often appears that a rejection is provoked or
encouraged. We can interpret this as an attempt to control this painful experience or as a way
to relive the painful emotion in an attempt to be able to cope with rejection. In addicts, we
often see this tendency to repeat the traumatic experience.
Also traumatic experiences in adults can lead to drug and alcohol abuse and addiction.
Addiction to drugs and alcohol is frequently seen among war veterans, civilian war refugees
and other migrants. After the Vietnam war many returning veterans were found to suffer from
a post traumatic stress disorder. This disorder occurred more frequently if the soldiers had
been exposed to heavy fighting. In many cases there was a tendency towards drug or alcohol
abuse, a percentage of 30% was found in research carried out in Texas among Vietnam
veterans (Kooyman, 2003)
In general, it can be said that traumatic experiences in childhood as well as traumas occurring
at a later age can lead to an addiction to drugs or alcohol.
Factors in the family.
Factors in the family such as physical or sexual abuse of the child, or problems between
parent can lead to problematic drug use and addiction.
The
drug problem of the addicted child draws the attention away from other problems in the
family. Stanton and Todd (1975) pointed out the tendency of the addict, who has stopped
using drugs and had successfully started to live his own life to relapse into his old habits of
drug abuse and to return home when a crisis in the family has occurred.
In
the history of addicts we often find traumatic situations in the families which they belong to
such as: incest and sexual abuse (in female addicts we find percentages up to 90% ) , suicides,
the sudden death of a parent, admission to a psychiatric hospital, divorce, (Aron, 1975 ). In a
large number of the male addicts admitted there are also experiences of sexual abuse in
childhood. In an American survey carried out among 732 patients in treatment clinics for
addiction, it was found that 55% of the woman and 29% of the men had had incest contacts
(Glover c.s., 1996). In a survey among hard-drug users in Rotterdam, Prins found that serious
emotional deprivation had taken place in childhood in two-thirds of the cases (Prins, 1995).
Social factors.
Influences from peers can lead to abuse of drugs and addiction especially if it fills the need to
belong to a group.
Factors in society such as the pressure of poverty, unemployment, immigration and war can
lead to addiction. Only a small percentage of addicted war veterans from Vietnam continued
their addiction after they had returned home.
The medical model
In the medical model the doctor is responsible and in charge of the treatment.
The role of a patient as can be described as follows: he is relieved from normal role
obligations, he is not regarded as responsible for his situation, he is expected toe see his

situation as undesired, to leave the role of the patient as soon as this is considered medically
justified and being obliged to seek help (Parsons, 1951).
The patient is passive and not responsible for his disease. The disease can be treated with
prescribed medication.
A positive results of seeing addiction as a disease instead of a moral unacceptable behaviour
(as was often the case in the past) is the inclusion of treatment of addiction in the hospital
treatment system. However the danger of viewing the addicted patient as not responsible for
his addicted behaviour is lead to the opinion that he cannot do something himself to change
his condition. This view is undermining his already low self esteem.
Addiction is a self-inflicted disorder with multiple causes.
The self help philosophy of the therapeutic communities
The philosophy of the original therapeutic communities for addicted persons is based on selfhelp and mutual help.
The addicted person is not seen as the problem as in the medical model, but as a person who
has a problem. The self help philosophy of the therapeutic communities says that the addict is
responsible for his addiction. It was you put the needle in your arm, you who put the drugs or
alcohol in your mouth and You can stop doing that, You alone can do it, but you cannot
do it alone.
In the early TCs using this concept, the staff consisted almost entirely of recovered addicts,
often graduates of the same programs.
The roots of Therapeutic communities are in Synanon, the self help community founded in
California, not by a professional, but by a recovered alcoholic, Charles Dederich. The
residents helped each other to abstain from drugs and alcohol through emotional
confrontations of negative behaviour together with responsible concern (Casriel, 1963).
With the help of ex-Synanon members, professionals founded therapeutic communities in
New York. Their goal was to have addicts return to society, living a rewarding life,
independent of substances or treatment programs. These first therapeutic communities in New
York were based on Synanons philosophy of self-help through mutual help and responsible
concern. Almost all staff were recovered addicts. These programs served as a role model for
many therapeutic communities on all continents (DeLeon, 2000).
The first time that I realised that the therapy in therapeutic communities is the community
itself, was when I visited Daytop Village in the year 1974. Msgr. William OBrien, the
president of Daytop, had taken me to the therapeutic community Parksville. They had seven
staff for 150 residents, some time before they had had only four staff. I then realised that the
therapy was the community itself and not the activities of the staff. The staff were teaching
the philosophy of self help, mutual help and responsible concern. They had made their way
without higher education and credentials to positions of therapeutic and administrative
leadership. Staff members were role models for the residents and residents could be future
staff.
In
the therapeutic community the philosophy is: learning to help yourself with the help of others.
There is a big difference between a therapeutic community and a medical model clinic. There
are strict rules in a therapeutic community: no drugs or alcohol, no violence or threat of
violence and no sexual acting-out. Conflicts are dealt with in emotional group meetings, there
is no individual psychotherapy, role models of older residents are important elements of the
system. All activities, including cooking, cleaning and administration are therapy. When you
enter a therapeutic community there are residents at the reception. It is their house as opposed
to a professional receptionist in a clinic. The staff in the therapeutic community is not always

in their office but has close contacts with the residents and give them a hug when they leave
the therapeutic community to go to the re-entry house (Kooyman, 2005).
In Europe, many therapeutic communities were established by professionals with the help of
staff from programmes in the U.S.A. (Kooyman, 2001). They added recovered addicts to their
staff. The professionals started to introduce specific therapies in the therapeutic communities,
such as psychodrama, bonding therapy groups and family therapy as a useful addition to the
programme. On the other hand the professionals in the therapeutic communities often felt that
they had learned little that was useful to them for their work in a therapeutic community. They
have to learn how to stop helping and learn how to teach the residents to help themselves.
They often feared that the ex-addict staff member was far better at the job and that their
professional training was of no value for their work. As a result of this insecurity and the
need to help, the professionals introduced treatments conflicting with the self-help principle.
They started individual therapy sessions in the therapeutic community, or they introduced
therapies such as psychoanalytic group therapies or T.A. (transactional analysis) groups
(Kooyman, 2002).
Several therapeutic communities in Europe have later become institutions with the staff
providing therapy. This is in conflict with the original philosophy of a system where the
resident can learn to solve his problems by experience with the help of role models.
Some therapeutic communities in the Netherlands, that were originally medical model
hospitals, have been changed again into medical model clinics. In the therapeutic community
Essenlaan for instance in Rotterdam, the original director, who was a nurse, was replaced by a
psychologist. Soon all ex-addicts were removed from the staff, individual therapy was
introduced, encounter groups and parent meetings were stopped. The programme was
shortened to three months and finally modelled into a three-month medical model clinic with
low successful outcome, which was closed a few years later. The drug addicts are now
treated with medication together with alcoholics in a large medical model clinic of the same
treatment organisation.
New regulations in several European countries make it difficult to hire ex-addict staff without
a finished professional training. In many therapeutic communities in Europe, ex-addicts in the
staff disappeared altogether. In the Netherlands recovered addicts, working in induction
programs in prisons, were replaced by social workers. These new professionals often have no
idea what is therapeutic in the therapeutic community. They do not know from their own
experience what is happening to a resident in the programme. They feel more secure in the
role of helper rather than that of the teacher setting limits on destructive behaviour.
What is therapeutic in a therapeutic community?
In a drug free environment the resident can learn to cope with stress without the help of drugs.
He can learn that an angry confrontation by a fellow resident can be a sign of concern instead
of a rejection. In groups, in particular in special groups such as in bonding psychotherapy
groups, he can overcome his fear of physical closeness and emotional openness. ( Casriel,
1971, Hffler-Zimmer, 1996, Stauss, 2006).
The structure, concepts and the environment of the therapeutic community is the main
therapeutic element. All what is programmed in the twenty four hour environment is therapy,
also the cleaning of the house and the cooking in the kitchen.
At least fifteen therapeutic factors can be in a therapeutic community.
These fifteen therapeutic factors, are (Kooyman, 1992, 1993, 1996):

The substitute family.

In this family the resident can grow in a safe environment
The consistent philosophy.
The philosophy can easily be understood, explained and supported by all members.
The therapeutic structure.
The structure offers a safe and secure environment with few but clear rules in which the
resident can learn to seek responsibilities and to be able to deal with mistakes.
The balance between therapy, autonomy and democracy.
To much therapy can result in avoiding responsibility, to much democracy can make the
environment anti-therapeutic (Kooyman, 1975), the autonomy of the individual is limited by
being part of a group.
Social learning through social interaction.
The resident learns to function in different roles. Through feed-back he gains insight in to his
own behaviour.
Learning through crisis.
Maturation can develop through a series of crises. Reintegration follows after the crisis
situation has been mastered.
The therapeutic impact of all activities.
Everything happening in the therapeutic community is therapy: the work, the different jobs,
the different roles in the community.
Responsibility of the resident for his behaviour.
The residents are told not to play the victim by blaming their failure to others or society. They
have to learn that they need help, that they can ask for help and that they are able to help
themselves as well as others.
Increase of self-esteem by accomplishment.
By overcoming the fear of failing step by step, by "acting as if " the resident becomes no
longer afraid to fail. As a result the self esteem of the resident is raised. The increased self
esteem in itself diminishes the fear of failure and rejection.
Internalisation of a positive value system.
The resident learns to be honest, to confront and criticise negative and self-destructive
behaviour and attitudes.
Confrontation of behaviour.
The resident learns to verbalise his inner conflicts. He learns to confront the behaviour of
others, the same behaviour that he does not like of himself. He learns, that being confronted
does not mean being rejected. He learns that it is not necessary to be perfect to be loved as he
might have believed as a child. In fact he sees that the opposite may be the case. He learns
that confrontation is not directed at the person but at the behaviour.
Positive peer pressure.
In the same way, that peer pressure may have been a factor in starting to use drugs, positive
peer pressure makes a person to abstain from drugs and develop positive behaviour.
Learning to understand and express emotions.
In
encounter groups and other therapy groups the resident learns to make contact with and
express emotions. He learns to overcome his fear for expressing anger, fear and pain and
finally to express positive emotions such as pleasure and love, which are usually still more

difficult to express than negative ones. Painful memories of traumatic experiences in the past
can be worked through in therapy groups.
Changing negative attitudes into positive ones.
Most addicts have negative views of themselves in relation with others such as: "I am not
lovable", "I am not good enough" and "I don't have the right to exist". That last attitude is
very common among addicts, although they often only realize during therapy groups, that
they have such an attitude. The negative attitudes developed in early childhood. It helped then
to survive, but it became a great handicap when they grew older. Therapy groups such as
bonding psychotherapy can help to overcome this negative self-fulfilling prophecy on life
(Casriel, 1972).
Improvement of the relationship with the family of origin.
In therapy groups " unfinished business" with parents can be worked through with parents
symbolically present (empty chairs, role-played by staff members or other residents). Parents
and other relatives are involved in group activities. The relationships with the relatives are
renewed with the help of staff members after a period of no contact.
These fifteen therapeutic factors of a therapeutic community are all essential for the
therapeutic process. If any of these are not present the treatment will be less effective.
The
therapeutic community should not be replaced by a model that keeps the addict a dependent
patient, not responsible for his or her treatment as is the case in an institution or in a medical
model clinic. Treatment programmes should not only should be directed at the symptom; the
abuse of drugs, but also at solving the causes of the addiction and at preparing the person for a
drug free life. In that view so-called harm reduction programmes can not be regarded as
treatment.
Conclusion
In the therapeutic community the addict can learn to ask for help to solve problems, can learn
to trust himself and others, can learn how to make mistakes and not feel a failure as a person.
He can learn to sustain long lasting friendships and not being afraid of success. He can also
learn how to respond to stress and how to have pleasure without the use of drugs or alcohol.
The self help philosophy characterized by: self help through mutual help, a drug free
environment, a positive value system, positive peer pressure, role models and learning
through experience should be left intact. The therapeutic communities must remain
therapeutic.
Although professional input is valuable to the therapeutic communities in improving the
quality of the work and adding scientific evaluation, it should never replace the basic
philosophy of self-help and mutual help.
References
Aron W.S.(1975). Family background and personal trauma among drug addicts in the USA:
implications for treatment. Brit. J. of Addiction, 70, 295-305.
Barr, H & Antes, D. (1980). Seven years after treatment: A follow-up study of drug addicts
and alcohol addicts treated in Eagleville Hospitals Inpatient Program. Final Report to
N.I.D.A.. Eagleville Hosp. Research Report, Eagleville, Penn.
Casriel, D. (1963). So fair a house: The story of Synanon. Prentice Hall Inc. Englewood
Cliffs, N.Y.
Casriel, D. (1971). A scream away from happiness. Grosset & Dunlap, New York, N.Y.

Cramer, E. and G.M. Schippers.(1994). Prediction of relapse to frequent heroin use and thge
role of methadone prescription. Drug and Alcohol Dependence, Vol. 79, (2), 231-240.
De Bruijn, C, van den Brink, W. de Graaf, R & Vollebergh, W. (2005). Alcohol abuse and
dependence criteria as predictors of a chronic course of alcohol use disorders in the general
population. Alcohol , 40, 441- 446.
De Jong, C.A.J., Schellekens A.F.A., Ellenbroek B., Franke, B. & Verkes, R-J.. (2006).
Results: Human genetics. In: Verslaving, 2, 14-26, ZonMW, Den Haag.
De Leon, G. (2000). The Therapeutic Community. Theory, Model, Springer Publ. Comp.,
New York, NY.
Dijk, W.K. van (1971). Complexity of the Dependence Problem: Interaction of Biological
Psychogenic and Sociogenic Factors in Drug Dependence in: H.M. van Praag (ed), Biochemical and
Pharmacological Aspects of Dependence and Reports on Marijuana Research, 26-32, Boon, Haarlem.

Enoch, M.A. (2003). Pharmacogenomics of alcohol response and addiction. Am J.

Pharmacogenomics, 3 (4), 217-233.
Glover, N.M., T.P. Janikowski, J.J. Benschoff. (1996). Substance Abuse and Past Incest
Contact, a National Perspective. Journ. of Substance Abuse Treatment, 13, 185-193.
Janssen, O. & Swierstra, K. (1983).On defining hard core addicts, Inst. Criminologie, Univ.
Groningen.
Hfler- Zimmer D. & Kooyman, M.(1996). Attachment transition, addiction and therapeutic
bonding. An integrative approach. In: Journ. of Substance Abuse Treatment, 13(6), 511-519.
Kooyman, (1975). From chaos to a structured Therapeutic Community. Treatment Program
on Emiliehoeve, a farm for young addicts. Bulletin on Narcotics, 27 (1),.19-26.
Kooyman, M. (1986). The psychodynamics of therapeutic communities for treatment of
heroin addicts. In: De Leon & Ziegenfuss (Eds.) Therapeutic Communities for addictions.
Readings in Theory, Research and Practice, 29- 41. Charles C. Thomas, Springfield, Ill.
Kooyman, M. (1992). The Therapeutic Community for Addicts, Intimacy, Parent Involvement
and Treatment Outcome. Universiteitsdrukkerij Erasmus Universiteit Rotterdam
Kooyman, M. (1996). La communidad terapeutica para drogodependientes. Intimidad,
implicacion de los padres y exito del tratamiemto. Ediciones Mensajero., S.A. Sancho de
Azpeitia,2, 48014 Bilbao.
Kooyman, M. (2000) Trauma and addiction. In: Greenberg, B. (ed.). Proceedings of the 20th
WFTC World Conference of Therapeutic Communities 26-29. Walden House San Francisco.
Kooyman, M. (2001). The History of Therapeutic Communities: a View from Europe. In:
Therapeutic Communities for the Treatment of Drug Users; B. Rawlings and R. Yates,
Editors, Jessica Kingsley Publishers, London.
Kooyman, M. (2002). The risks of having professionals in the staff of Self-help Therapeutic
Communities and the advantages of employing recovered addicts. Paper presented at the 21th
WFTC World Conference, Melbourne.

Kooyman M. (2003). Trauma, addiction and therapy. Paper presented at the 5th Global
Conference on Drug Prevention, Rome, September 2003
Kooyman, M (2005) The therapeutic community, a self-help programme or an institution.
Paper presented at the 10th EFTC Conference on Rehabilitation and Drug Policy in
.
Heraklion, Crete, May 12th 2005
Kooyman, M. ( 2006) The self help Philosophy of the therapeutic community and the medical
model. Paper presented at the 23rd WFTC World Confernce in New York. September 2006
Kooyman, M. (2007). The different asapects of addiction and the therapeutic community
approach. Paper presented at the 12th EFTC Conference in Ljubljana, Slovenia.
Kolk, B.V. van der (1987). The separation cry and the trauma response. Chapter in:
Psychological Trauma, 31-62, Washington.
McLellan, A.T. (2005). J.R.McKay, R.Forman, J.Cacciola and J.Kemp, Reconsidering the
evaluation of addiction treatment: from retrospective follow-up to concurrent recovery
monitoring, Addiction, 100, (40, 447-458).
Parsons, T. (1951). The social system, Glencoe, The Free Press, New York, N.Y.
Prins, E.H. (1995). Maturing Out. Thesis. Erasmus University, Rotterdam.
Schippers, G.M. and Broekman, T.G. (2006).The course of drug dependence. In: Verslaving ,
deel 3, 34- 44, ZonMW Den Haag, .
Schippers, G.M. and Broekman,.T.G. (2006). The course of alcoholdependence. In:
Verslaving , deel 3, 6-26, ZonMW, Den Haag.
Stanton,M.D. and T.C. Todd (1982), The family therapy of drug abuse and addiction,
Guildford Press, New York
Stauss, K. (2006), Bondingpsychotherapie, Grundlagen und Methoden, Ksel-Verlag,
Germany.