Therapeutic Community Treatment Research Articles

The Revolving Prison Door for Drug-Involved Offenders: Challenges and Opportunities

This article examines the role of drugs in increasing the incarcerated population in the United States. Research is increasingly demonstrating the effectiveness of treatment for incarcerated populations in reducing recidivism and drug use, especially treatment in a therapeutic community (TC). Transitional services that include TC treatment in a work release setting greatly reduce recidivism and relapse, as do aftercare services. Although treatment options are increasing in prisons, there are many more who could benefit from treatment than receive it. Much remains unknown about how to best reach drug-involved offenders to stop the revolving door of drug addiction and incarceration. This article touches on many relevant areas ripe for further research.

Exploring the self-reported sexual problems and concerns of drug-dependent males and females in modified, therapeutic community treatment.

The importance of sexual trauma and sexual problems in the treatment of chemically dependent persons has long been recognized by clinicians working with this population. This study was undertaken to describe the degree of self-reported sexual problems and concerns for 163 males admitted into a Philadelphia- or New York City-based modified therapeutic community (TC) program and 100 females admitted to the same New York City program. Results indicated that the majority of men and women identified some sexual problems and concerns shortly after being admitted, with females in the New York City sample endorsing sexual problems more often than males in the Philadelphia or New York City samples. These findings are considered in view of the fact that these clients' sexual problems were usually not addressed on their Master Treatment Plans. The implications of addressing or not addressing these sexual problems are considered.

Institutional behaviour and time in treatment among psychopaths admitted to a prison-based therapeutic community.

Previous research has indicated that psychopathy is associated with high levels of institutional misconduct and high attrition rates in therapeutic communities. However, most of this work has been conducted with North American populations. In the present study, data is presented on institutional behaviour and time in therapy for 104 inmates admitted to Grendon Therapeutic Prison. The results indicated that high scores on the Hare Psychopathy Checklist Revised were significantly associated with failure to progress from the assessment unit onto a therapy wing and the number of adjudications and security information reports. A trend was found for psychopathy to be associated with shorter periods in therapy, but this just failed to reach significance. The results confirm previous research on the association between psychopathy and institutional misconduct and provide some support for the association between psychopathy and early termination of treatment in therapeutic communities. A number of methodological issues are discussed.

Measuring client clinical progress in therapeutic community treatment. The therapeutic community Client Assessment Inventory, Client Assessment Summary, and Staff Assessment Summary.

The therapeutic community (TC) Client Assessment Inventory (CAI), Client Assessment Summary (CAS), and Staff Assessment Summary (SAS) are instruments developed from a comprehensive theory of TC treatment and recovery. They measure client self-report and staff evaluation of client progress along 14 domains of behavior, attitude, and cognitive change. The present article reports on the development of the instruments and findings from an analysis of data on 346 clients in TC treatment; including scale properties and cross-sectional client differences by treatment tenure. The instruments were administered over a 1-year period at two residential TC facilities. Findings indicate that both client and staff instruments reliably differentiate client clinical changes during treatment and client self-ratings are initially consistently higher than staff ratings. Clarifying and measuring changes in the individual during treatment is the first step in the effort to understand the change process and what steps can be taken to improve treatment effectiveness.

Exploring the Expressed Spiritual Needs and Concerns of Drug-Dependent Males in Modified, Therapeutic Community Treatment

Two hundred male admissions into one of two inner-city residential substance abuse treatment programs were evaluated for spirituality/religious concerns with the Substance Abuse Problem Checklist (Carroll, 1983). Results indicated considerable levels of religious/spiritual needs and concerns for residents of both a Philadelphia and New York City modified therapeutic community program. Implications of these identified needs are identified and considered.

Hospital adjustment in personality disorder patients admitted to a therapeutic community milieu.

This study investigated aspects of adjustment to the therapeutic community milieu in a group of personality disorder patients. Eighty-one patients consecutively admitted to the Cassel Hospital for medium/long-term residential treatment between April 1994 and October 1997 comprised the sample. The adjustment to the milieu was rated on the Hospital Adjustment Scale, while outcome was evaluated at 6-monthly intervals using a battery of self-rated and rater-based instruments. The aims of the study were: (a) to identify demographic and pre-admission clinical variables that would predict adjustment to the therapeutic regime; (b) to study the relationship between hospital adjustment and external social adjustment; and (c) to investigate the hypothesis that hospital adjustment and internally and externally directed aggression do not predict clinical outcome. The results showed that pre-admission level of global functioning and a previous history of substance misuse are the most significant predictors of hospital adjustment. No significant association between hospital adjustment and external social adjustment was found. Neither hospital adjustment not level of aggressiveness predicted outcome at 12 months. The implications of these results for therapeutic community treatment of personality disorder are discussed.

Adolescent Amphetamine Users in Treatment: Client Profiles and Treatment Outcomes

This study compares client profiles of adolescent amphetamine users to those of nonusers and examines the multivariate prediction of posttreatment drug use, criminal, and HIV risk behavior outcomes in the year following their separation from treatment. Data were collected as part of a larger longitudinal study on a sample of 938 adolescents who were admitted to residential therapeutic community drug treatment programs across the eastern United States and Canada from April of 1992 through April of 1994. A subsample of 485 adolescents were reinterviewed one year after their separation from treatment. Findings indicated that amphetamine users tended to be white, older, and have parents with higher education and occupational levels than nonusers. However, they also had more psychopathology, more extensive drug use and criminal histories, and engaged in more HIV-risk behaviors than nonusers. Additionally, amphetamine users tend to come from homes where one or both parents used illicit drugs, drank regularly, or had a mental illness, and they often reported histories of childhood maltreatment. Analyses of the one-year follow-up data indicated that being an amphetamine user was not related to treatment outcome after the client's demographic characteristics. overall drug use severity, and treatment completion were taken into account. Therefore, therapeutic community treatment appears to be an effective means of treating adolescent amphetamine users.

Motivation for Treatment in a Prison-Based Therapeutic Community

Current research concludes that participation in postprison aftercare is critical to the effectiveness of prison-based therapeutic community (TC) treatment. This conclusion makes it imperative to understand the client determinants of retention in prison treatment, particularly continuance in postprison aftercare. Currently, however, little data exist as to client predictors of seeking and remaining in prison-based TCs or entering postrelease aftercare. In the present study, significant relationships were obtained between initial motivation (i.e., Circumstances, Motivation, Readiness [CMR] scores), retention, aftercare, and outcomes in a sample of substance abusers treated in a prison-based TC program. Implications are discussed for theory, research, and treatment policy.

Therapeutic Communities: Diversity in Treatment Elements

This study addresses the need to describe the diversity of therapeutic community (TC) programs. The Survey of Essential Elements Questionnaire (SEEQ) was used to develop a typology of TC programs based on 19 programs that identified themselves as traditional or modified TCs in the Drug Abuse Treatment Outcome Studies (DATOS). These traditional and modified TCs differed in adherence to the elements of TC treatment, on operational characteristics, and in client mix. Differences in treatment philosophy and approach included the emphasis on self- reliance, and the use of work as a therapeutic agent for traditional TCs. There were also trends for traditional TC programs to utilize community-as-method, provide educational and vocational training, and include family members as part of therapy. Modified programs showed a greater tendency to rely on counselors. Implications of the findings for program quality, health care policy, and research are discussed.

Three-Year Outcomes of Therapeutic Community Treatment for Drug-Involved Offenders in Delaware: From Prison to Work Release to Aftercare

Delaware researchers have argued for a continuum of primary (in prison), secondary (work release), and tertiary (aftercare) therapeutic community (TC) treatment for drug-involved offenders. Previous work has demonstrated significant reductions in relapse and recidivism for offenders who received primary and secondary TC treatment 1 year after leaving work release. However, much of the effect declines significantly when the time at risk moves to 3 years after release. Further analyses reveal that program effects remain significant when the model takes into account not simply exposure to the TC program, but, more importantly, program participation, program completion, and aftercare. Clients who complete secondary treatment do better than those with no treatment or program dropouts, and those who receive aftercare do even better in remaining drug- and arrest-free.

Three-Year Reincarceration Outcomes for In-Prison Therapeutic Community Treatment in Texas

Longer term in-prison therapeutic community (ITC) outcome studies are needed, along with more attention on who benefits most from these programs. This study examined reincarceration records for 394 nonviolent offenders during the 3 years following prison. Those who completed both ITC and aftercare were the least likely to be reincarcerated (25%), compared to 64% of the aftercare dropouts and 42% of the untreated comparison groups. Furthermore, high-severity aftercare completers were reincarcerated only half as often as those in the aftercare dropout and comparison groups (26% vs. 66% and 52%). The findings support the effectiveness of intensive treatment when it is integrated with aftercare, and the benefits are most apparent for offenders with more serious crime and drug-related problems.

A Cost-Effectiveness Analysis of In-Prison Therapeutic Community Treatment and Risk Classification

Policy makers need scientifically based information to help them to determine which correctional treatment alternatives are effective and economically viable. Three-year outcome data from 394 parolees (291 treated, 103 untreated comparison) were examined to determine the relative cost-effectiveness of prison-based treatment and aftercare, controlling for risk of recidivism. Findings showed that intensive services were cost-effective only when the entire treatment continuum was completed, and that the largest economic impact was evident among high-risk cases. Therefore, assignments to correctional treatment should consider an offender's problem severity level, and every effort should be made to engage them in aftercare upon release from prison.

Clarifying the nature of therapeutic community treatment. The Survey of Essential Elements Questionnaire (SEEQ).

This study reports on the extent to which Therapeutic Community (TC) agencies share a common set of beliefs about the essential elements of TC treatment. The Survey of Essential Elements Questionnaire (SEEQ), a TC theory-based instrument, was used in a field survey of 59 directors of agencies identified as TCs through their membership in Therapeutic Communities of America (TCA). Results showed a high degree of concordance in the perceived importance of a common set of treatment elements identified as essential to the TC modality. Two clusters of TC-oriented agencies, identified as Traditional and Modified, were determined based on beliefs in the importance of the elements. Results were seen as validating the TC formulation from which the SEEQ items were drawn. Implications on the potential use of the SEEQ as a means of codifying TC treatment for research, training, and quality assurance are discussed.

Ohio's Prison-Based Therapeutic Community Treatment Programs for Substance Abusers

ABSTRACT This study evaluates the Ohio Department of Alcohol and Drug Addiction Services' prison-based therapeutic communities (TCs) for inmates with histories of drug abuse. The study compares arrests/charges following release from prison among 487 inmates with TC experience and 242 inmates without TC treatment. Outcome measures were based on arrest and charge statistics. The results of survival analysis and Cox hazards model analysis indicate that length of time in the TC is crucial to a positive outcome. Controlling for age, gender, ethnicity, and education, inmates who spent at least 180 days in a TC were significantly less likely than those with less time in treatment or no TC exposure to be re-arrested/charged with violent or drug-related crimes one year after release.

Therapeutic community provision at regional and district levels

Aims and methodThe aim of the study was to investigate changes in service utilisation following therapeutic community treatment for patients with severe personality disorder. The study examined service usage, in the form of acute psychiatric admissions, of a series of 52 admissions to a residential therapeutic community in the three years before and year after admission.ResultsThere was a reduction in the mean duration of acute psychiatric admissions after treatment, this was greater for extra-contractual referral patients than local district patients.Clinical ImplicationsThis study replicates results from previous studies. It also suggests that more accessible local services may be able to intervene earlier in patients' psychiatric careers preventing heavy use of acute services. We argue for greater provision of therapeutic community treatment for severe personality disorder.

Changes in personality characteristics in women treated in a therapeutic community.

We examined changes in mood and personality characteristics in a sample of cocaine-dependent women being treated in a therapeutic community (TC). Forty-six women completed the Beck Depression Inventory (BDI), the Hamilton Anxiety Scale (HAM-A), and the Millon Clinical Multiaxial Inventory-II (MCMI-II) on admission and 12 months after discharge from the TC. On admission, the group was characterized by clinically significant scores on the BDI, HAM-A, and the MCMI-II Avoidant, Dependent, Antisocial, Passive-aggressive, Self-defeating, and Borderline scales. On follow-up, significant improvement in functioning was suggested by decreases in scale scores on the BDI, HAM-A, and MCMI-II Avoidant, Dependent, Self-Defeating, and Borderline Scales, but not for the MCMI-II Antisocial and Passive-Aggressive scales. These results suggest substantial positive effects of TC treatment on personality characteristics and functioning, but also indicate that TC treatment may not habilitate all critical personality deficits.

Neuropsychological therapeutic community treatment for individuals with schizophrenia.

Neuropsychological therapeutic community treatment for individuals with schizophrenia.

Therapeutic Communities in Prisons

English This review of research into prison therapeutic communities (TCs) covers democratic TCs, which treat personality disorders, and hierachical TCs, which treat drug abusers. The article outlines the history and establishment of TCs in Britain, USA, Canada and Europe and also describes typical TC treatment regimes and examines research into treatment outcome. It highlights the fact that outcome research rests mainly on reconviction and recidivism figures, despite criticisms of these as measures. Research shows that TCs can reduce offending and a relationship between length of time in therapy and positive outcome as been a consistent finding. However, TCs are established sparingly in prisons and historically have been relatively short-lived.

Modified therapeutic community for homeless mentally ill chemical abusers. Sociodemographic and psychological profiles.

This paper, the first in a series of reports from a field study on the efficacy of modified therapeutic community (TC) treatment for homeless mentally ill chemical abusers, presents sociodemographic profiles, psychiatric diagnosis, and psychological symptom data on 342 homeless mentally ill chemical abusing clients seeking treatment in mental health community residence settings. The findings reflect the multidimensional deficits, social dysfunctionality, and severity of psychopathology of the study sample. The paper discusses the implications of these findings for program design and program planning, with special reference to modified TC programs.

Developing Comprehensive Prison-Based Therapeutic Community Treatment for Women

SUMMARY Experience and research have affirmed that treatment works for drug-involved offenders. Nonetheless, adapting these treatment models for drug-involved women offenders remains a challenge. One treatment modality, the therapeutic community (TC), has proven effective for women. This article discusses the adaptations necessary to the TC model to make it appropriate and effective for drug-involved women. Several themes are discussed including the staffing structure, staff-client interactions, the safety of the treatment environment, characteristics of the residential community, programming, and the treatment program's relationship with various social service agencies. In addition, the program elements specific to effective TCs for women in the criminal justice setting are also discussed. The experiences of developing, implementing and operating a specific TC for drug-involved female offenders provide examples of establishing an effective TC for women.