Program Profile: Modified Therapeutic Community for Individuals With Mental Illness and Chemical Abuse (MICA) Disorders Who Commit Offenses

Study Title: Modified TC for MICA Offenders: Crime Outcomes (which is associated with outcomes Criminal activity, Reincarceration, and Drug and alcohol offenses)

Research Design

Sacks and colleagues (2004) conducted a randomized trial to examine the effect of a modified therapeutic community and aftercare on recidivism for men with co-occurring serious mental illness and substance use disorders who were incarcerated in the San Carlos Correctional Facility in Pueblo, Colorado.

Sample

Incarcerated individuals who had co-occurring disorders were placed in an eligibility pool for random assignment to one of two conditions, modified therapeutic community (the treatment group) or the standard mental health treatment (the control group) that received psychiatric services consisting of medication, weekly individual therapy and counseling, and specialized groups. Men in the modified therapeutic community group could enter the aftercare program after their release from prison (designated the modified therapeutic community plus aftercare group), while others did not (designated the modified therapeutic community only group). The CrimeSolutions review of this study focused on outcomes for the modified therapeutic community plus aftercare treatment group compared with the standard mental health control group. Men from the eligibility pool who chose to participate entered the study 12–18 months before their parole release date, and only those who represented a clear danger to themselves or others were excluded. There were 92 men in the modified therapeutic community treatment group and 93 men in the control group. Of the 92 men in the treatment group, 43 participated in the modified therapeutic community plus aftercare group.

 Men in the modified therapeutic community plus aftercare treatment group were on average 36 years old; 51 percent were white, 33 percent were Black, 14 percent were Hispanic, and 2 percent were another ethnicity; 97 percent had an Axis I or II disorder; and they had spent an average of 73.4 months incarcerated. Men in the standard mental health treatment control group were on average 32.5 years old; 45 percent were white, 30 percent were Black, 22 percent were Hispanic, and 3 percent were another ethnicity; 97 percent had an Axis I or II disorder; and they had spent an average of 54.1 months incarcerated. There were statistically significant differences between individuals in the total modified therapeutic community group (which included those who participated only in the modified therapeutic community and those who participated in the modified therapeutic community plus aftercare) and the standard mental health treatment control group. Individuals in the  control group were younger, were more likely to be unemployed in the year prior to incarceration, had used alcohol at an earlier age, and were less likely to report drugs as the main reason for criminal activity in the year prior to incarceration. A comparison of baseline characteristics between the modified therapeutic community plus aftercare group and the control group was not reported.   

Outcome Measures/Data Collection

The two main outcome measures were reincarceration and criminal activity (which included 17 illegal activities), and both included new crimes only. Criminal activity was further explored by separately examining offenses related to alcohol or drug use. Outcomes were measured using responses to a self-report instrument (the Center for Therapeutic Community Research Baseline Interview Protocol) and Colorado Department of Corrections records. All measures referred to activity or status during the first 12 months post-prison release. Data were collected from subjects at baseline (on entry into the prison treatment programs) and at 12 months post-prison release to compare the groups on crime outcomes in the first year outside prison.

Statistical Analysis

An intent-to-treat analysis was conducted. Logistic regression was used to test for differential group change on all dichotomous outcome measures (e.g., any criminal activity). The regression models consisted of the 12-month post-prison outcome, variables for the treatment condition, and five covariates (the outcome variable at baseline, age, age at first incarceration, employment during the year prior to the baseline interview, and the number of residences during the year prior to the baseline interview). Subgroup analyses were conducted with participants who were reincarcerated and with participants who reported criminal activity at 12 months post-prison release. A subgroup analysis was also conducted with sex offenders in the sample; however, because there were no sex offenders in the modified therapeutic community plus aftercare group (the treatment group of interest), these results were omitted from the CrimeSolutions review.

Citation:

Sacks, Stanley, JoAnn Y. Sacks, Karen McKendrick, Steven Banks, and Joseph Stommel. 2004. “Modified TC for MICA Offenders: Crime Outcomes.” Behavioral Sciences and the Law 22:477–501.

Study Title: Randomized Trial of a Reentry Modified Therapeutic Community for Offenders with Co-Occurring Disorders: Crime Outcomes (which is associated with outcomes Criminal activity, Reincarceration, and Drug and alcohol offenses)

Research Design

Sacks and colleagues (2012) extended the previous examination of a modified therapeutic community plus aftercare program (Sacks et al. 2004) through a randomized trial of a reentry modified therapeutic community that focused on recidivism outcomes.

Sample

The sample was recruited from nine Colorado Department of Corrections prison facilities as individuals prepared for release to community corrections. Males were eligible to participate if they –

• Had been diagnosed with co-occurring mental and substance use disorders (based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic categories for mental disorders and the Colorado Department of Corrections Standardized Offender Assessment administered on prison entry).
• Had participated in one of two prison substance use treatment programs within the Colorado Department of Corrections, either a modified therapeutic community or standard services (substance use education and counseling).
• Were approved by the Community Corrections Board for placement in a community corrections facility.
• Were accepted by the provider agency for placement in a community corrections facility. 

Prior to randomization to study conditions, eligible men were stratified according to the type of treatment they received during incarceration (i.e., a prison modified therapeutic community program with integrated mental health and substance use services, or standard prison services, which included substance use and mental health services). Men were then individually assigned using a list of random numbers to the experimental reentry modified therapeutic community condition (n = 71) or to the control parole supervision and case management condition (n = 56). The experimental condition had the same goals as a modified therapeutic community with new components added to meet the needs of individuals with co-occurring disorders who were leaving prison, including weekly group psychoeducation classes. The control group received standard services provided to individuals in Colorado who were making the transition from prison to the community. 

Men in the experimental condition were on average 39.5 years old; 55 percent white, 17 percent Hispanic, 13 percent Black, and 15 percent another race or mixed race. Men in the control condition were on average 36.5 years old; 57 percent white, 18 percent Hispanic, 18 percent another race or mixed race, and 7 percent Black. There were statistically significant differences between the groups (men in the experimental condition were less likely to have a high school diploma or GED, reported more lifetime arrests, and were more likely to inject drugs in the six months prior to incarceration). These differences were controlled for in the analysis.

Outcome Measures/Data Collection

Outcomes included reincarceration (new offenses), criminal activity, and alcohol and drug offenses. Data were obtained from official records from the Colorado Department of Corrections online database and the Center for the Integration of Research and Practice Interview Protocol, which collected self-report information on 21 illegal activities. 

Statistical Analysis

An intent-to-treat analysis was conducted. Logistic regressions were used to compare rates of reincarceration and criminal activity for men in the reentry modified therapeutic community condition compared with men in the control condition after 12 months. Covariates in the analyses included high school diploma/GED, number of arrests, and intravenous drug use (measures that were statistically significant between the two groups); ethnicity (due to its use historically for assessing similar populations); and treatment type during prison (to examine potential group differences based on in-prison treatment). An additional covariate, criminal activity in the 12 months prior to involvement with the criminal justice system, was included in the comparison of criminal activity post-prison release. No subgroup analysis was conducted.  

Citation:

Sacks, Stanley, Michael Chaple, JoAnn Y. Sacks, Karen McKendrick, and Charles M. Cleland. 2012. “Randomized Trial of a Reentry Modified Therapeutic Community for Offenders with Co-Occurring Disorders: Crime Outcomes.” Journal of Substance Abuse Treatment 42:247–259.

Study Title: Outcome Data for MICA Clients After Participation in an Institutional Therapeutic Community (which is associated with outcomes Reincarceration and Use of multiple substances)

Research Design

Van Stelle and Moberg (2004) used a quasi-experimental design to assess the effectiveness of a prison-based therapeutic community on participants’ substance use and reincarceration 12 months after their reentry to the community.

The institutional therapeutic community examined in this study was the Mental Illness-Chemical Abuse Treatment Program at the Oshkosh Correctional Institution in Wisconsin, a 9–12 month modified therapeutic community that offered integrated treatment for males who were incarcerated and had substance use or dependence and severe and persistent mental health issues, such as a diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or delusional disorder. In addition to the therapeutic community, this model included other components: institutional outreach (supportive services such as pre-release preparation and relapse prevention groups offered to participants who remained incarcerated after the therapeutic community) and community outreach (e.g., the facilitation of ongoing mental health substance use treatment in the community). The outreach specialists in the community outreach component also completed the follow-up assessments.

Sample

There were 212 individuals admitted to the institutional therapeutic community from October 1, 1997, to September 30, 2001. The comparison group was composed of 66 men who were also dually diagnosed and met diagnostic and eligibility criteria but did not receive institutional therapeutic community services, because they had less than 18 months to mandatory release and therefore would likely be released prior to completion of the treatment program. Men in the treatment group were an average of 36.4 years old, and the majority were either white or Black and were diagnosed with schizophrenia. Men in the comparison group were an average of 36 years old, and the majority were either white or Black and had been diagnosed with either schizophrenia, schizoaffective disorder, or psychotic disorder. There were statistically significant differences at baseline between the two groups. Men in the comparison group were more likely to receive a diagnosis of polysubstance dependence and had more conduct reports in the six months prior to baseline than men in the institutional therapeutic community.

Outcome Measures/Data Collection

The outcomes of interest were substance use (abstinent from substances since release) and reincarceration (returned to prison). Outcomes were measured through data gathered from the institutional therapeutic community participant database (that summarized participant data regarding assessment results, program services, and their performance unique to the project), corrections data systems, and inmate case file review. Parole agents for both the treatment and comparison groups were asked to provide information related to participants’ substance use, mental health, and criminal justice outcomes post-release. The Wisconsin Corrections Integrated Program Information System database and the Offender Active Tracking System database were used to access information regarding participants’ current incarceration status; dates of, and reasons, for incarceration in the state prison system; parole status information; and additional information on custody in county jails (participants were tracked monthly). Data were collected at baseline (program admission), at the end of the therapeutic community component, at release to community, three months after release to community, and at 12 months after release. The CrimeSolutions review of this study focused on outcomes for the institutional therapeutic community participants (n = 70) and the comparison group (n = 21) at the 12-month follow-up.

Statistical Analysis 

Intent-to-treat analysis was used. Logistic regression was conducted as the primary analytic technique for dichotomous dependent measures, and ordinary least squares regression was employed for continuous measures. Covariates included age, ethnicity, and reading level. No subgroup analysis was conducted. 

Citation:

Van Stelle, Kit R., and D. Paul Moberg. 2004. “Outcome Data for MICA Clients After Participation in an Institutional Therapeutic Community.” Journal of Offender Rehabilitation 39(1):37–62.

Study Title: Modified Therapeutic Community Treatment for Offenders with MICA Disorders: Substance Use Outcomes (which is associated with outcomes Illegal drug use, Alcohol use, and Use of multiple substances)

Research Design

Sullivan and colleagues (2007) used the full study sample from Sacks and colleagues (2004) to examine the effect of the modified therapeutic community treatment program on substance use outcomes for persons with mental illness and substance use disorders who had been convicted of an offense. 

Sample

Men in the San Carlos Correctional Facility were randomly assigned to the treatment or control group as described in Sacks and colleagues (2004). The sample consisted of 139 individuals for whom 12-month post-prison release data were available. Seventy-five subjects made up the treatment group, including 32 individuals who participated in the modified therapeutic community in prison only and 43 who continued treatment in the aftercare program. Sixty-four subjects who received the standard mental health services formed the control group. The treatment group was all male and on average 35.8 years old; 52 percent were white, 31 percent were Black, 12 percent were Hispanic, and 5 percent were another ethnicity; 96 percent had an Axis I or II disorder; and they had spent an average of 57.7 months incarcerated. The control group was the same as described in Sacks and colleagues (2004). There were statistically significant differences between the treatment and control groups at baseline. Individuals in the control group were younger, were more likely to be unemployed in the year prior to incarceration, had used alcohol at an earlier age, and were less likely to report drugs as the main reason for criminal activity in the year prior to incarceration.  

Outcome Measures/Data Collection

The outcomes of interest were any substance use (a combined measure of drug use and alcohol used to intoxication) and separate measures for any illegal drug use and alcohol use to intoxication. Data for the study were obtained from standardized self-report instruments, which were administered by trained interviewers, and from records of the Colorado Department of Corrections. Data were measured at three points: 1) baseline (admission into the program), 2) 6 months after release from prison, and 3) 12 months post-release (about 24 months after baseline data collection). The CrimeSolutions review of the study examined the outcomes at 12 months post-release.

Statistical Analysis 

Differences between the groups were examined with logistic and ordinary least squares regression in intent-to-treat analyses. The multivariate analysis controlled for age at baseline, age at first illegal activity, months spent in prison, employment, stable housing, suicide attempts, and living with a relative (other than parents) while growing up (covariates selected based on observed differences between groups at baseline and stepwise regression analyses conducted to detect predictors of change in substance use). No subgroup analysis was conducted.

Citation:

Sullivan, Christopher J., Karen McKendrick, Stanley Sacks, and Steven Banks. 2007. “Modified Therapeutic Community Treatment for Offenders with MICA Disorders: Substance Use Outcomes.” The American Journal of Drug and Alcohol Abuse 33:823–32.