Treatment for MICAs: design and implementation of the modified TC

Program Retention and Perceived Coercion in Three Models of Mandatory Drug Treatment

Despite the proliferation of drug courts and other mandatory treatment models, few studies have compared the impact of different program features comprising these models. This study compared three groups of clients (N = 330) mandated to the same long-term residential treatment facilities. Study participants were referred from two highly structured programs or from more conventional legal sources, such as probation or parole agents. Analyses showed that these clients varied substantially in their perceptions of legal pressure, and these perceptions generally corresponded to the programs' different coercive policies and practices. Retention analyses confirmed that the odds of staying in treatment for six months or more was nearly three times greater for clients in the most coercive program compared to clients in the third group. Results support the use of structured protocols for informing clients about legal contingencies of participation and how that participation will be monitored, and developing the capacity to enforce threatened consequences for failure.

Motivation and readiness for drug treatment: differences by modality and special populations

The purpose of this research is to expand our knowledge of motivational factors among admissions to various substance abuse treatment modalities and among those entering special programs. Differences in motivation are reported in a convenience sample of more than 6,000 admissions to 38 programs. Results from multilevel analyses show (a) an ordered increase in motivation by settings from referral to outpatient, to methadone maintenance, and to the highest levels in residential programs and (b) significantly lower motivation among admissions to programs for special populations. Results are discussed in relation to the demand characteristics of treatment and non-recovery reasons for entering treatment.

Evaluation of the therapeutic community treatment model in Thailand: policy implications for compulsory and prison-based treatment

This study, conducted in 2005 to 2007, presents results that are based on a proscriptive cohort design. The sample consisted of 769 residents in 22 drug user treatment programs who stayed in treatment for at least 30 days to one year; 510 former residents (66%) from 21 programs (95%) were interviewed again at a 6-month post-treatment follow-up assessment. A majority of the participants were male, lived with family or relatives, had completed only primary school, and had a full-time or a part-time job prior to entering treatment. The participating therapeutic community (TC) programs were a mixture of volunteer, compulsory-probation, and prison-based programs. In-person interview data and urine testing showed that the self-reported drug use prevalence rates are reliable. The results show large positive treatment effects on 30-day and 6-month illegal drug use and small to medium effects on the severity of alcohol use and related problems. A multilevel regression analysis suggests that residents' reduced stigma, adaptation of the TC model, and frequency of alcohol and drug use-related consequences partially predict treatment success. Study limitations and policy implications are discussed.

Does HIV serostatus affect outcomes of dually diagnosed opiate dependents in residential treatment?

Backgroung– Little is known about specific treatment needs of mentally ill clients abusing substances and infected by HIV. The major gap concerns residential programmes.Aims– To explore differences in outcomes between seropositive and seronegative dually diagnosed opiate dependent clients who participated in a residential therapy programme.Methods– Data were gathered on 154 clients treated in a therapeutic community in Milan between October 1999 and September 2004. Odds ratios with 95% confidence intervals were used to study the association between HIV serostatus and outcome.Results– At 12-month follow-up, seropositive clients were more likely to relapse.Conclusions– The impact of HIV seropositivity on behavioural outcomes should be taken into consideration when planning residential programmes for the HIV (+) dually diagnosed population. Further research could test the need of incorporating dedicated treatments into existing programmes.

Declaration of interest: None.

Modified therapeutic community for co-occurring disorders: single investigator meta analysis

This paper presents the results of a meta-analysis for a single investigator examining the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring substance use and mental disorders (COD). The flexibility and utility of meta-analytic tools are described, although their application in this context is atypical. The analysis includes 4 comparisons from 3 studies (retrieved N = 569) for various groups of clients with COD (homeless persons, offenders, and outpatients) in substance abuse treatment, comparing clients assigned either to an MTC or a control condition of standard services. An additional study is included in a series of sensitivity tests. The overall findings increase the research base of support for the MTC program for clients with COD, as results of the meta-analysis indicate significant MTC treatment effects for 5 of the 6 outcome domains across the 4 comparisons. Limitations of the approach are discussed. Independent replications, clinical trials, multiple outcome domains, and additional meta-analyses should be emphasized in future research. Given the need for research-based approaches, program and policy planners should consider the MTC when designing programs for co-occurring disorders.

A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders

Substance use disorder is the most common and clinically significant co-morbidity among clients with severe mental illnesses, associated with poor treatment response, homelessness and other adverse outcomes. Residential programs for clients with dual disorders integrate mental health treatment, substance abuse interventions, housing and other supports. Ten controlled studies suggest that greater levels of integration of substance abuse and mental health services are more effective than less integration. Because the research is limited by methodological problems, further research is needed to establish the effectiveness of residential programs, to characterize important program elements, to establish methods to improve engagement into and retention in residential programs and to clarify which clients benefit from this type of service.

Therapeutic community drug treatment success in Peru: a follow-up outcome study

Background

The purpose of this study was to assess the impact of drug abuse treatment in Peru that used the therapeutic community (TC) model. Program directors and several staff members from all study treatment facilities received two to eight weeks of in-country training on how to implement the TC treatment model prior to the follow-up study.

Methods

This outcome study involved 33 TC treatment facilities and 509 former clients in Lima and other cities in five providences across Peru. A retrospective pre-test (RPT) follow-up design was employed in which 30-day use of illegal drugs and alcohol to intoxication was measured at baseline retrospectively, at the same time of the six-month follow-up. In-person interview data were collected from directors of 73 percent of the eligible TC organizations in January and February 2003 and from former 58 percent of the eligible TC former clients between October 2003 and October 2004. Drug testing was conducted on a small sample of former clients to increase the accuracy of the self-reported drug use data.

Results

Medium to large positive treatment effects were found when comparing 30-day illegal drug and alcohol use to intoxication before and six months after receiving treatment. As a supplemental analysis, we assumed the 42 percent of the former clients who were not interviewed at the six month assessment had returned to drugs. These results showed medium treatment effects as well. Hierarchical Generalized Linear Modeling (HGLM) results showed higher implementation fidelity, less stigma after leaving treatment, and older clients, singly or in combination are key predictors of treatment success.

Conclusion

This study found that former clients of drug and alcohol treatment in facilities using the TC model reported substantial positive change in use of illegal drugs and alcohol to intoxication at a six-month follow-up. The unique contribution of this study is that the results also suggest attention should be placed on the importance of implementing the TC drug abuse treatment model with fidelity. Further, the results strongly suggest that TC drug abuse treatment programs should incorporate follow-up activities that attempt to neutralize community negative reactions (perceived stigma) independent of other factors.

Treatment outcomes for female offenders: relationship to number of Axis I diagnoses

This article describes a study that examined the relationship between multiple Axis I mental health diagnoses and treatment outcomes for female offenders in prison substance abuse treatment programs. Preliminary findings of the effectiveness of therapeutic community (TC) treatment, modified for female offenders, relative to a control cognitive behavioral treatment condition, are presented. The hypothesis--that participants who fit into multiple diagnostic categories have more dysfunctional symptoms and behaviors at baseline--was confirmed; however, a hypothesized relationship between the number of Axis I diagnoses and 6 month treatment outcomes across five domains (mental health, trauma exposure, substance use, HIV needle risk behaviors, and HIV sexual risk) was not supported. Across all Axis I mental health groups, TC treatment was significantly more effective than the control condition overall, as well as on measures of mental health symptoms and HIV sexual risk. These findings suggest that this TC treatment program, as modified, is an effective model for women with varied diagnoses and diagnostic complexities.

Enhanced outpatient treatment for co-occurring disorders: Main outcomes

This study, which was conducted in an outpatient substance abuse treatment program, randomly assigned clients with mental health symptoms to either a control group, which received basic program services, or an experimental group, which was configured as a modified therapeutic community (TC) track, with the addition of modified TC features and three specific elements-psychoeducational seminar, trauma-informed addictions treatment, and case management. The experimental group had significantly better outcomes as compared with the control group on measures of psychiatric severity and on the key measure of housing stability; no difference was observed for substance use, crime, and employment. The findings must be qualified because (a) only 3 of 34 representative measures (<10%) showed significant differential treatment effects and (b) analysis revealed partial implementation of the enhancements. The study provides modest support for the effectiveness, on specific outcomes, of outpatient substance abuse treatment programs that add modified TC features and targeted interventions to strengthen their capacity to treat co-occurring disorders.

Modified therapeutic community for co-occurring disorders: a summary of four studies

This article summarizes results from four research studies (n = 902) that examined the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring disorders (most with severe mental disorders). Significantly better outcomes for MTC were found across four experimental versus control comparisons on 23.1% (12 of 52) of primary outcome measures of substance use, mental health, crime, HIV risk, employment, and housing. Study limitations included the potential for selection bias, limited measurement of program fidelity, and insufficient examination of the relationship between treatment dose and outcome. Future research should emphasize clinical trial replications, multiple outcome domains, and further development of continuing care models. Given the need for research-based approaches, the MTC warrants consideration when program and policy planners are designing programs for co-occurring disorders.

Mental disorders and drug abuse in persons living with HIV/AIDS

This article reviews the literature on the prevalence of mental and substance use disorders among persons living with HIV/AIDS. Drug use, both injection and non-injection, substantially increases the risk for HIV infection. While injection drug users have the highest prevalence rates for HIV, substantially elevated rates of HIV infection are also present among crack cocaine users and individuals with substance use disorders generally. Persons with HIV/AIDS and a mental and/or substance use disorder have highly variable patterns of accessing services. Persons with HIV/AIDS who have a serious mental illness are more highly involved with services than other groups. Most individuals with co-occurring disorders report some involvement with outpatient primary medical care, although ancillary services such as mental health and substance abuse treatment, transportation assistance, and case management improve involvement in medical care. Women with HIV/AIDS and co-occurring mental and substance use disorders experience unique vulnerabilities, particularly those related to exposure to traumatic events. Given the complexity of needs with which triply or multiply diagnosed individuals present, effective treatment programmes are likely to be those that provide some degree of integrated care.

Changing the world: the design and implementation of comprehensive continuous integrated systems of care for individuals with co-occurring disorders

This article has described the CCISC model and the process of implementation of systemic implementation of co-occurring disorder services enhancements within the context of existing resources. Four projects were described as illustrations of current implementation activities. Clearly, there is need for improved services for these individuals, and increasing recognition of the need for systemic change models that are effective and efficient. The CCISC model has been recognized by SAMHSA as a consensus best practice for system design, and initial efforts at implementation appear to be promising. The existing toolkit may permit a more formal process of data-driven evaluation of system, program, clinician, and client outcomes, to better measure the effectiveness of this approach. Some projects have begun such formal evaluation processes, but more work is needed, not only with individual projects, but also to develop opportunities for multi-system evaluation, as more projects come on line.

Development of Service Intensity Criteria and Program Categories for Individuals with Co-Occurring Disorders

Many patients present a clinical situation in which psychiatric symptomatology and substance related symptomatology are inextricably intertwined. A paradox exists for these patients, in that both the addictions and mental health systems of care, and the level of care assessment methodologies associated with each system, are designed for one type of disorder only, or only one disorder at a time. As a result, these individuals are perceived as "system misfits." Our inability to assess these patients accurately and place them appropriately contributes to poor outcomes and high costs. These costs consist of expensive utilization of scarce system resources. There is a growing need for a more integrated methodology for level of care assessment, in which both psychiatric and substance symptomatology can be assessed simultaneously to generate a wider array of programmatic interventions for individuals with co-occurring disorders. This article describes efforts to build upon the Patient Placement Criteria published by the American Society of Addiction Medicine, Second Edition (ASAM PPC-2) to develop a revised instrument that is much more capable of evaluating the placement needs of individuals who present with combinations of psychiatric and substance symptomatology.

The promise of prison-based treatment for dually diagnosed inmates

The Stay'n Out therapeutic community was created 25 years ago, the first rigorously evaluated prison program that demonstrated recidivism reduction. Since then, there has been a growing appreciation for the recidivism-reducing benefit of substance abuse treatment and the general understanding has been reached that prison treatment for substance abuse is good for the public interest. A number of replicated outcome studies have led to increases in treatment capacity in most state correctional systems, primarily utilizing the therapeutic community model. In contrast, efforts to introduce treatment for offenders with co-occurring mental illness and substance abuse disorders (COD) are only beginning. This article describes developments in prison substance abuse treatment and reentry programs and offers some guiding observations from prison substance abuse treatment history that could facilitate the development of COD treatment. Lessons learned include that: public safety (i.e., recidivism reduction) is a primary goal; personal accountability as a basic treatment value facilitates cooperation between treatment and correctional staff; self-help approaches foster more ambitious treatment goals than just symptom reduction; and well-run treatment programs often ease the burden of correctional administration.

Improved psychological status in a modified therapeutic community for homeless MICA men

An adaptation of the drug-free therapeutic community (TC) model to homeless men with comorbid mental illness and chemical addiction (MICA) was evaluated with respect to change in psychological status over the course of a six-month residential treatment. Psychological status was assessed by: the Symptom Checklist-90-R (SCL90-R), Beck Depression Inventory (BDI), Shortened Manifest Anxiety Scale (SMAS), and Tennessee Self-Concept Scale (TSCS). A total of 52 out of an original study cohort of 124 residents were followed in longitudinal analyses to treatment midpoint, with a subset of 34 assessed through treatment completion. Significant, widespread psychological improvements were found during both the first and second half of treatment; it would appear that distress reduction was ongoing throughout treatment, with intrapersonal preceding interpersonal relief. The premise of applying a socially-based treatment to this population is discussed in light of these findings.

The mentally ill in jails and prisons: towards an integrated model of prevention

Jails and prisons have become a final destination for persons with severe mental illness in America. Addiction, homelessness, and fragmentation of services have contributed to the problem, and have underscored the need for new models of service delivery. Project Link is a university-led consortium of five community agencies in Monroe County, New York that spans healthcare, social service and criminal justice systems. The program features a mobile treatment team with a forensic psychiatrist, a dual diagnosis treatment residence, and culturally competent staff. This paper discusses the importance of service integration in preventing jail and hospital recidivism, and describes steps that Project Link has taken towards integrating healthcare, criminal justice, and social services. Results from a preliminary evaluation suggest that Project Link may be effective in reducing recidivism and in improving community adjustment among severely mentally ill patients with histories of arrest and incarceration.

Co-occurring mental and substance use disorders: promising approaches and research issues

This paper surveys the mental health and drug user treatment literature, identifying promising approaches and research issues in the treatment of co-occurring mental illness and substance use disorders. The prevalence and classification of co-occurring disorders are briefly reviewed, and selected treatment models currently in use are described. Three models are cited as representing particularly promising approaches--comprehensive integrated treatment, assertive community treatment, and the modified therapeutic community--and best practices are summarized. This paper proposes a research agenda focused on relevant emerging treatment issues.