Date of Review: March 2008
The Modified Therapeutic Community (MTC) for Persons With Co-Occurring Disorders is a 12- to 18-month residential treatment program developed for individuals with co-occurring substance use disorders and mental disorders. MTC is a structured and active program based on community-as-method (that is, the community is the treatment agent) and mutual peer self-help. A comprehensive treatment model, MTC adapts the traditional therapeutic community (TC) in response to the psychiatric symptoms, cognitive impairments, and reduced level of functioning of the client with co-occurring disorders. Treatment encompasses four stages (admission, primary treatment, live-in reentry, and live-out reentry) that correspond to stages within the recovery process. The stage format allows gradual progress, rewarding improvement with increased independence and responsibility. Goals, objectives, and expected outcomes are established for each stage and are integrated with goals specific to each client in an individual treatment plan. Staff members function as role models, rational authorities, and guides.
The MTC model retains most of the key components, structure, and processes of the traditional TC but makes three key adaptations for individuals with co-occurring disorders: It is more flexible, less intense, and more personalized. For example, MTC reduces the time spent in each activity, deemphasizes confrontation, emphasizes orientation and instruction, uses fewer sanctions, is more explicit in acknowledging achievements, and accommodates special developmental needs.
When used in prison settings, MTC has included additional programmatic and operational adaptations to address the particular circumstances of offenders with co-occurring disorders. Programmatic alterations have included an emphasis on criminal thinking and behavior that recognizes the interrelationships of substance abuse, mental illness, and criminality, while operational adjustments have included adding security personnel to the treatment team and making other changes to comply with the security requirements of correctional facilities. In other community applications, outpatient substance abuse treatment programs have adopted certain features of the MTC model to improve services for their clients who have co-occurring disorders.
Descriptive Info Outcomes Ratings Study Populations Studies/Materials Replications Contacts
Descriptive Information
Topics | Co-occurring disorders |
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Areas of Interest | Alcohol (e.g., underage, binge drinking), Criminal/juvenile justice, Homelessness |
Outcomes |
Outcome 1: Substance use Outcome 2: Criminal behavior Outcome 3: Psychological problems Outcome 4: Employment Outcome 5: Economic benefit Outcome 6: Housing stability |
Study Populations |
Age:
26-55 (Adult) Gender: Female, Male Race: Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified (See Study Populations section below for percentages by study) |
Settings | Correctional, Outpatient, Residential, Suburban, Urban |
Implementation History | First implemented in 1992, MTC for Persons With Co-Occurring Disorders has been used at 25 sites with an estimated 12,600 participants. Outside the United States, the intervention has been implemented in Auckland, New Zealand, and Montreal, Canada. |
Replications | This intervention has been replicated. (See Replications section below) |
Adaptations | Adaptations to the intervention have been made for a prison population, primarily to incorporate a programmatic emphasis on criminal thinking. In addition, some features of the intervention have been added to intensive day treatment programs in community outpatient substance abuse treatment centers. |
Adverse Effects | No adverse effects, concerns, or unintended consequences were identified by the applicant. |
Public or Proprietary Domain | Mix of public and proprietary |
Costs |
The average cost of providing this intervention to one client for 12 months is $29,255 (1994 estimates), about the same cost of providing a client with co-occurring disorders with 12 months of standard residential treatment ($29,638, also 1994 estimates). The average cost for a 3-day intensive staff training workshop is $5,000. This estimate assumes that an organization is converting an existing therapeutic community into an MTC for persons with co-occurring disorders. Organizations interested in training must have at least one master's-level social worker on staff to support the mental health services provided to clients. The program manual is available for free from the National Development and Research Institutes at http://www.ndri.org/ctrs/cirp.html. |
Outcomes
Outcome 1: Substance use
Description of Measures |
In one study, substance use was evaluated using three self-report measures: frequency of alcohol intoxication, number of different types of illegal drugs used (0-17), and highest frequency of illegal drug use on a scale from 0 (none) to 8 (more than once daily). All three reports were obtained at baseline, at 12 months after baseline, and at each client's last follow-up point (long-term follow-up), which was more than 24 months after baseline, on average. In another study, substance use was evaluated using six self-report measures across the first 12 months after release from prison: any illegal drug use, alcohol used to intoxication, any substance use (combined measure of drug use and alcohol used to intoxication), frequency of alcohol used to intoxication, drug use severity, and days until substance use (relapse). |
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Key Findings |
Homeless clients with co-occurring disorders were sequentially assigned to a low-intensity MTC condition, a moderate-intensity MTC condition, or usual care. Compared with the high-intensity MTC condition, the low-intensity condition placed fewer demands on clients (e.g., clients had more freedom to leave the facility) and provided clients with more staff assistance. Usual care incorporated a variety of treatment and nontreatment options that were typically less specific to the needs of homeless clients with co-occurring disorders, not as well organized, and less cohesive in perspective or approach relative to the MTC conditions.
In a randomized controlled trial (RCT), male prison inmates with co-occurring disorders were assigned either to a 12-15 month in-prison MTC program modified for a prison population, followed by a voluntary, 6-month aftercare MTC program in a community corrections facility after release, or to a mental health treatment condition of variable duration (11 months, on average). Adaptations to MTC included a programmatic emphasis on criminal thinking and behavior, adjustments to comply with security guidelines, inclusion of security personnel on the treatment team, psychoeducational classes, and cognitive behavioral protocols. The control condition consisted of psychiatric medication services, weekly individual therapy and counseling, and mandated cognitive behavioral and anger management group therapy.
|
Studies Measuring Outcome |
Study 1,
Study 2
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below) |
Study Designs | Experimental, Quasi-experimental |
Quality of Research Rating | 2.7 (0.0-4.0 scale) |
Outcome 2: Criminal behavior
Description of Measures |
In one study, criminal behavior was measured by two self-report items: number of different types of crimes committed (0-16) and total number of crimes committed for each type reported on a scale from 0 (none) to 9 (more than 500). Self-reports of criminal behavior were obtained at baseline, at 12 months after baseline, and at each client's last follow-up point (long-term follow-up), which was more than 24 months after baseline, on average. In another study, criminal behavior was measured by the following three self-report items across the first 12 months after release from prison: reincarceration, number of new illegal activities (0-17), and drug/alcohol-related offenses. Self-reports were cross-checked against department of correction records. |
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Key Findings |
Homeless clients with co-occurring disorders were sequentially assigned to a low-intensity MTC condition, a moderate-intensity MTC condition, or usual care. Compared with the high-intensity MTC condition, the low-intensity condition placed fewer demands on clients (e.g., clients had more freedom to leave the facility) and provided clients with more staff assistance. Usual care incorporated a variety of treatment and nontreatment options that were typically less specific to the needs of homeless clients with co-occurring disorders, not as well organized, and less cohesive in perspective or approach relative to the MTC conditions.
In an RCT, male prison inmates with co-occurring disorders were assigned either to a 12-15 month in-prison MTC program modified for a prison population, followed by a voluntary, 6-month aftercare MTC program in a community corrections facility after release, or to a mental health treatment condition of variable duration (11 months, on average). Adaptations to MTC included a programmatic emphasis on criminal thinking and behavior, adjustments to comply with security guidelines, inclusion of security personnel on the treatment team, psychoeducational classes, and cognitive behavioral protocols. The control condition consisted of psychiatric medication services, weekly individual therapy and counseling, and mandated cognitive behavioral and anger management group therapy.
|
Studies Measuring Outcome |
Study 1,
Study 2
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below) |
Study Designs | Experimental, Quasi-experimental |
Quality of Research Rating | 2.8 (0.0-4.0 scale) |
Outcome 3: Psychological problems
Description of Measures |
In one study, psychological problems (depression and anxiety symptoms) were measured using the Beck Depression Inventory (BDI) and the Short Form of the Taylor Manifest Anxiety Scale. The BDI is a 21-item self-report instrument that measures past-week depressive symptoms. Total scores vary from 0 to 63 and indicate whether depression is minimal (0-13), mild (14-19), moderate (20-28), or severe (29-63). The Short Form of the Taylor Manifest Anxiety Scale is a 20-item, true/false, self-report questionnaire measuring past-week anxiety symptoms. Self-reports were obtained at baseline, at 12 months after baseline, and at each client's last follow-up point (long-term follow-up), which was more than 24 months after baseline, on average. In another study, psychological problems were measured using the Global Appraisal of Individual Needs (GAIN) at baseline and the 12-month follow-up. The GAIN is a standardized, semistructured interview with eight main sections (background, substance use, physical health, risk behaviors, mental health, environment, legal, and vocational) that is designed to support the diagnosis, placement, and outcome monitoring of patients and the economic analysis of an intervention. |
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Key Findings |
Homeless clients with co-occurring disorders were sequentially assigned to a low-intensity MTC condition, a moderate-intensity MTC condition, or usual care. Compared with the high-intensity MTC condition, the low-intensity condition placed fewer demands on clients (e.g., clients had more freedom to leave the facility) and provided clients with more staff assistance. Usual care incorporated a variety of treatment and nontreatment options that were typically less specific to the needs of homeless clients with co-occurring disorders, not as well organized, and less cohesive in perspective or approach relative to the MTC conditions.
In an RCT, clients with co-occurring disorders who were admitted to an outpatient substance abuse day treatment program were assigned to one of two intensive conditions: MTC modified for day treatment or usual care. Both conditions consisted of 3 hours of treatment per day, 3 days per week. The modified MTC condition incorporated community-enhancing meetings for dual recovery taken from the residential MTC model and added a psychoeducational seminar, trauma-informed addictions treatment, and case management. Usual care was a basic day treatment program that provided individual as well as group therapy and counseling that focused on substance use and relapse prevention.
|
Studies Measuring Outcome |
Study 1,
Study 3
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below) |
Study Designs | Experimental, Quasi-experimental |
Quality of Research Rating | 3.0 (0.0-4.0 scale) |
Outcome 4: Employment
Description of Measures | Employment was evaluated using one self-report measure. Response options were 0 (none), 1 (part-time irregular or odd jobs), 2 (part-time regular), and 3 (full-time). Self-reports were obtained at baseline, at 12 months after baseline, and at each client's last follow-up point (long-term follow-up), which was more than 24 months after baseline, on average. |
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Key Findings |
Homeless clients with co-occurring disorders were sequentially assigned to a low-intensity MTC condition, a moderate-intensity MTC condition, or usual care. Compared with the high-intensity MTC condition, the low-intensity condition placed fewer demands on clients (e.g., clients had more freedom to leave the facility) and provided clients with more staff assistance. Usual care incorporated a variety of treatment and nontreatment options that were typically less specific to the needs of homeless clients with co-occurring disorders, not as well organized, and less cohesive in perspective or approach relative to the MTC conditions.
|
Studies Measuring Outcome |
Study 1
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below) |
Study Designs | Quasi-experimental |
Quality of Research Rating | 2.8 (0.0-4.0 scale) |
Outcome 5: Economic benefit
Description of Measures |
Economic benefit was measured as the average incremental financial benefit over the cost of each condition, the net financial benefit over the cost of each condition, and the benefit-to-cost ratio associated with each condition, calculated in 1994 dollars. Financial benefits were evaluated as the estimated cost savings to society expected to accrue from self-reported declines in criminal activity, increased productivity (employment earnings), and decreased health care utilization occurring from 12 months before to 12 months after admission (baseline). Monetary conversion factors (unit cost estimates) were applied to changes in criminal activity, employment earnings, and health care utilization. The economic benefits of treatment were defined as the dollar value associated with changes in each of these outcome domains. Costs associated with the study conditions were calculated using the Drug Abuse Treatment Cost Analysis Program (DATCAP), an analysis package that estimates both the accounting and economic costs of program implementation, including the full value of all resources, such as donations and subsidies. |
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Key Findings |
Homeless clients with co-occurring disorders were sequentially assigned to a low-intensity MTC condition, a moderate-intensity MTC condition, or usual care. Compared with the high-intensity MTC condition, the low-intensity condition placed fewer demands on clients (e.g., clients had more freedom to leave the facility) and provided clients with more staff assistance. Usual care incorporated a variety of treatment and nontreatment options that were typically less specific to the needs of homeless clients with co-occurring disorders, not as well organized, and less cohesive in perspective or approach relative to the MTC conditions.
|
Studies Measuring Outcome |
Study 1
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below) |
Study Designs | Quasi-experimental |
Quality of Research Rating | 2.4 (0.0-4.0 scale) |
Outcome 6: Housing stability
Description of Measures | Housing stability was measured using the GAIN, a standardized, semistructured interview with eight main sections (background, substance use, physical health, risk behaviors, mental health environment, legal, and vocational) that is designed to support the diagnosis, placement, and outcome monitoring of patients and the economic analysis of an intervention. |
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Key Findings |
In an RCT, clients with co-occurring disorders who were admitted to an outpatient substance abuse day treatment program were assigned to one of two intensive conditions: MTC modified for day treatment or usual care. Both conditions consisted of 3 hours of treatment per day, 3 days per week. The modified MTC condition incorporated community-enhancing meetings for dual recovery taken from the residential MTC model and added a psychoeducational seminar, trauma-informed addictions treatment, and case management. Usual care was a basic day treatment program that provided individual as well as group therapy and counseling that focused on substance use and relapse prevention.
|
Studies Measuring Outcome |
Study 3
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below) |
Study Designs | Experimental |
Quality of Research Rating | 2.6 (0.0-4.0 scale) |
Ratings
Quality of Research Ratings by Criteria (0.0-4.0 scale)
Outcome | Reliability of Measures |
Validity of Measures |
Fidelity | Missing Data/Attrition |
Confounding Variables |
Data Analysis |
Overall Rating |
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Outcome 1: Substance use | 2.9 | 2.4 | 2.3 | 2.8 | 3.0 | 3.3 | 2.7 |
Outcome 2: Criminal behavior | 3.0 | 2.5 | 2.3 | 2.8 | 3.0 | 3.3 | 2.8 |
Outcome 3: Psychological problems | 3.8 | 3.8 | 2.0 | 2.5 | 3.0 | 2.8 | 3.0 |
Outcome 4: Employment | 3.0 | 2.5 | 2.0 | 2.5 | 3.0 | 3.5 | 2.8 |
Outcome 5: Economic benefit | 2.5 | 2.0 | 2.5 | 2.0 | 3.0 | 2.5 | 2.4 |
Outcome 6: Housing stability | 3.0 | 2.5 | 2.0 | 2.5 | 3.0 | 2.5 | 2.6 |
Study Strengths: Standard self-report instruments and measures were used and were augmented with collateral information in some cases (e.g., urine drug screens and department of correction records in the prison study). Self-reports of reincarceration are likely to be highly valid and reliable from the prison study, as they were checked against department of correction records. In the outpatient treatment study, housing was a good index of increased stability and reduced risk for homelessness. Intervention training was carried out by experts who provided ongoing supervision. The DATCAP economic analyses were strong in the homeless study.
Study Weaknesses: Reliability for the self-report of substance use and psychological problems was not specifically calculated in these study samples. In the absence of any independent verification, the validity of self-reported crime types and number of crimes committed as true index measures for criminal behavior in the homeless study is questionable. Additionally, there was no attempt to verify self-reported employment (e.g., using pay stubs) in the homeless study. Consequently, the cost-benefit analysis in the homeless study was weakened by the reduced reliability and validity of the behavioral change measures--self-reported criminal behavior and employment--on which it was based. There was no independent verification of intervention fidelity and no fidelity ratings for the usual care control groups in any of these studies.
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
Implementation Materials |
Training and Support |
Quality Assurance |
Overall Rating |
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3.5 | 2.5 | 2.5 | 2.8 |
Dissemination Strengths: The well-designed treatment manual provides program content, clear steps for implementing the program, and information on the intervention's goals and intended audience. Training and consultation are provided by the program developers to support initial and ongoing implementation. Several tools are provided to support quality assurance.
Dissemination Weaknesses: It may be difficult for implementers to see how the program materials fit together to frame an overall approach to implementation. Limited information is provided on staff roles, especially their interrelationships. The training materials include only minimal discussion of staff supervision. Detailed information addressing continued direct supervision of front-line staff to support quality assurance is not provided. The overall design for quality assurance is unclear.
Study Populations
The studies reviewed for this intervention included the following populations, as reported by the study authors. |
Study | Age | Gender | Race/Ethnicity |
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Study 1 | 26-55 (Adult) |
75.4% Male 24.6% Female |
70.2% Black or African American 18.1% Hispanic or Latino 11.7% White |
Study 2 | 26-55 (Adult) |
100% Male |
48.9% White 30.2% Black or African American 16.5% Hispanic or Latino 4.3% Race/ethnicity unspecified |
Study 3 | 26-55 (Adult) |
57.1% Female 42.9% Male |
78.8% Black or African American 13.1% White 8.1% Hispanic or Latino |
Studies and Materials Reviewed
The documents below were reviewed for Quality of Research and Readiness for Dissemination. Other materials may be available. For more information, contact the person(s) listed at the end of this summary. |
Quality of Research Studies
Study 1
French, M. T., McCollister, K. E., Sacks, S., McKendrick, K., & De Leon, G. (2002). Benefit-cost analysis of a modified therapeutic community for mentally ill chemical abusers. Evaluation and Program Planning, 25, 137-148.
Study 2
Study 3
Quality of Research Supplementary Materials
Sacks, S. (2007). CTCR interview protocols--Baseline & follow-up. Unpublished manuscript.
Sacks, S., Banks, S. M., McKendrick, K., Sacks, J. Y., & Cleland, C. M. (2007). Meta-analysis for single investigators and research teams. Manuscript submitted for publication.
Sacks, S., Sacks, J. Y., & Stommel, J. (2003). Modified therapeutic community program for inmates with mental illness and chemical abuse disorders. Corrections Today, 65(6), 90-99.
Readiness for Dissemination Materials
Overview of MTC dissemination materials
PowerPoint slides for training and technical assistance series:
- Co-Occurring Substance Use and Mental Disorders (COD)--Diagnoses, Symptoms, and Clinical Tips
- Evidence-Based and Consensus Practices for Treatment of Persons With Co-Occurring Disorders
- Modified Therapeutic Communities for People With Co-Occurring Disorders--Research Findings
- Modified Therapeutic Community for Clients With Mental Illness & Chemical Abuse (MICA) Disorders--Description of the Program
- Modified Therapeutic Community (MTC)--Principles of Implementation
- Overview of Screening and Assessment
Sacks, S., De Leon, G., Bernhardt, A., & Sacks, J. (1996). Modified therapeutic community for homeless mentally ill chemical abusers: Treatment manual. New York: National Development and Research Institutes/Center for Therapeutic Community Research.
Replications
Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research. |
Contact Information
Web site(s):
http://www.ndri.org/ctrs/cirp.htmlFor information about implementation:
JoAnn Y. Sacks, Ph.D.Deputy Director
Center for the Integration of Research and Practice
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor
New York, NY 10010
Phone: (212) 845-4429
Fax: (212) 845-4650
E-mail: jysacks@mac.com
For information about studies:
Stanley Sacks, Ph.D.Director
Center for the Integration of Research and Practice
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor
New York, NY 10010
Phone: (212) 845-4429
Fax: (212) 845-4650
E-mail: stansacks@mac.com
The NREPP review of this intervention was funded by the Center for Substance Abuse Treatment (CSAT).