This chapter presents the formulation of the therapeutic community (TC) as theory, model, and method. The TC has proven to be a powerful treatment approach for substance abuse and related problems in living. The TC is fundamentally a self-help approach, evolved primarily outside of mainstream psychiatry, psychology, and medicine. The TC’s basic approach of treating the whole person through the use of the peer community, which was initially developed to address substance abuse, has been amplified with a variety of additional services related to family, education, vocational training, and medical and mental health. The evolution of the TC reveals the vigor, resourcefulness, and flexibility of the TC modality to expand and adapt to change. The sophistication of the TC is evident in the fact that Therapeutic Communities of America (TCA) has established criteria and procedures for evaluating counselors and certifying their competency.

The idea of the therapeutic community (TC) recurs throughout history implemented in different incarnations. In its contemporary form, two major variants of the TC have emerged. One, in social psychiatry, consists of innovative units and wards designed for the psychological treatment and management of socially deviant psychiatric patients within mental hospital settings. In the other form, TCs have taken are as community-based residential treatment programs for addicts and alcoholics. This chapter explores the sources and evolution of these communities to illustrate how they contribute to the theoretical framework of the TC. It describes the direct and indirect influences shaping the essential elements of the modern TC. The early religious influences on the Oxford group and Alcoholics Anonymous (AA) reappear as elements of the modern TC. The search for an “essential TC” reveals a universal idea recurring in various forms throughout history: that of healing, teaching, support, and guidance through community.

In the therapeutic community (TC) perspective, the substance abuse disorder is not distinct from the substance abuser. A picture of dysfunction and disturbance of individuals entering treatment reflects a more fundamental disorder of the whole person. This chapter presents the TC view of the disorder in the context of current biomedical, social, and psychological understanding of chemical dependency. Overall, the picture that individuals present when entering the TC is one of health risk and social crises. In the TC perspective, drug abuse is a disorder of the whole person, affecting some or all areas of functioning. In the TC view, social and psychological factors are recognized as the primary sources of the addiction disorder. Substance abusers themselves cite a variety of reasons and circumstances as causes of their drug use. TC policy on the use of pharmacotherapy is currently undergoing modifications.

In the therapeutic community (TC) perspective, the core of addiction disorder is the “person as a social and psychological being” how individuals behave, think, manage emotions, interact, and communicate with others, and how they perceive and experience themselves and the world. This chapter details the TC view of the person in terms of typical cognitive, behavioral, emotional, social, and interpersonal characteristics. Residents in TCs display a variety of cognitive characteristics associated with their substance abuse and lifestyle problems. Residents in TCs have difficulties experiencing, communicating, and coping with feelings. Their lack of emotional self-management is associated with much of their self-defeating social behavior. The social and interpersonal context of community life in the TC provides a setting for the emergence of all varieties of guilt. Although the TC view of the person pictures a typical profile of characteristics and problems, it does not necessarily depict an addictive personality.

In the therapeutic community (TC), recovery is viewed as a change in lifestyle and identity. It is a view that can be contrasted with the conventional concept of recovery in medicine, mental health, and other substance abuse treatment approaches. In the public health experience of treating opioid addiction and alcoholism, drug abuse is viewed as a chronic disease, which focuses treatment strategies and goals on improvement rather than recovery or cure. The TC view of recovery extends much beyond achieving or maintaining abstinence to encompass lifestyle and identity change. This chapter outlines this expanded view of recovery and details the goals and assumptions of the recovery process. It presents the TC view of right living, which summarizes the community teachings guiding recovery during and after treatment. The terms “habilitation” and “rehabilitation” distinguish between building or rebuilding lifestyles for different groups of substance abusers in TCs.

The quintessential element of the therapeutic community (TC) approach is community. It is the element of community that distinguishes the TC from all other treatment or rehabilitative approaches to substance abuse and related disorders. TCs differ profoundly from other communities in their rationale and purpose. This chapter discusses the general characteristics of community as a treatment approach: its relationship to the TC perspective, its healing and learning properties, and its social and cultural features. It translates this approach into a specific method the components of which are the “active ingredients” in the treatment process. Residents in TCs have been labeled as bad or rebellious kids, dangerous addicts or criminals, failures or losers, sick or crazy. The negative social labels become embedded in self-perceptions regarding their social and personal identities. The community approach fosters change in the social and personal elements of identity.