Why the concept-based therapeutic community can no longer be called drug-free.

In the last two decades, a complex controversy has emerged in therapeutic community (TC) drug treatment programs, many of which are experiencing a marked increase in addicted clients with co-existing mental health disorders. This situation calls into question many theoretical and practical aspects of the TC approach to addiction recovery. Among the central issues: use of psychotropic medications for the increasing cases of comorbidity among substance abuse clients entering the TC, the influx of mental health professionals, and employment of a growing number of mental health interventions or services. The traditional drug-free self-help approach to drug treatment by the TC (with its own set of treatment interventions) and its historic dominance by ex-addicts or recovering persons as key staff are undergoing change. Integrating a biopsychosocial model into the traditional TC treatment modality requires a variety of adjustments that challenge the status quo in these programs. In particular, the use of psychotropic medications and mental health service providers in TC programs has improved the delivery of treatment to clients but at the same time it has created a cultural conflict for paraprofessional staff espousing the drug-free self-help philosophy. The clinical implications and organizational challenges of this predicament are described. Recommendations are provided on how to accept current health care realities without compromising the unique qualities of the TC approach.