JoAnn Y. Sacks

A Randomized Clinical Trial of a Therapeutic Community Treatment for Female Inmates: Outcomes at 6 and 12 Months After Prison Release

This random assignment study compared female offenders (n = 468) with substance use disorders in a prison therapeutic community program with those in a cognitive-behavioral intervention. The study demonstrates that all women benefitted from gender-sensitive prison treatment, but the therapeutic community was more effective in reducing drug use, criminal activity, and exposure to trauma and increasing mental health functioning and time until reincarceration during the year after prison. In addition, the ability to sustain and even improve behavior change after the women leave prison highlights the importance of providing accessible community-based continuity of mental health and substance abuse services during reentry.

Prison Therapeutic Community Treatment for Female Offenders: Profiles and Preliminary Findings for Mental Health and Other Variables (Crime, Substance Use and HIV Risk)

ABSTRACT This random assignment study compared women in a prison Therapeutic Community (TC) program with those in a cognitive-behavioral intervention. Over two thirds of study subjects received a lifetime diagnosis of severe mental disorder, nearly one-half received a diagnosis of PTSD, and virtually all reported exposure to trauma. Preliminary analysis (n = 314) found significantly better six-month post-prison outcomes for the TC group on measures of mental health, criminal behavior and HIV-risk behavior. These findings suggest the short-term effectiveness of prison TC treatment for female offenders with substance use disorders, and underscore the importance of adapting treatment to address mental health.

Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: Crime outcomes

This article describes a randomized study to determine the effectiveness of a reentry modified therapeutic community (RMTC) for offenders with co-occurring substance use and mental disorders (co-occurring disorders or COD). Men with COD, approved for community corrections placement postrelease, were recruited from nine Colorado prisons and stratified according to the type of treatment received while incarcerated (i.e., a prison modified therapeutic community [MTC] program or standard care). When released, each offender was randomly assigned either to the experimental RMTC (E-RMTC) condition (n = 71) or to the control parole supervision and case management (PSCM) condition (n = 56). An intent-to-treat analysis 12 months postprison release showed that the E-RMTC participants were significantly less likely to be reincarcerated (19% vs. 38%), with the greatest reduction in recidivism found for participants who received MTC treatment in both settings. These findings support the RMTC as a stand-alone intervention and provide initial evidence for integrated MTC programs in prison and in aftercare for offenders with COD.

Outcomes from a therapeutic community for homeless addicted mothers and their children.

A womens therapeutic community (TC) designed to prevent homelessness was evaluated using a quasi-experimental process. Propensity analysis selected comparable experimental (E) and comparison (C) participants. Significant improvements were found for the E group at the domain level, both in “psychological” dysfunction on symptoms (e.g., depression), and in “health,” including ratings of health and adherence to medication regimens. No significant difference was found at the domain level for “parenting” or “housing stabilization,” but specific outcomes did differ. For example, a greater number of children resided with the E group mothers who also assumed financial responsibility for more of their children.

TC-Oriented Supported Housing for Homeless MICAs

Abstract This article describes a TC-oriented aftercare program for homeless mentally ill chemical abusers (MICAs) in a supported housing facility, and presents some preliminary data on program effectiveness. The study divided the clients who had completed a residential modified TC program into two groups—those who participated in the TC-oriented supported housing program and those who did not. The data show similarities in the profile of the two groups. Improvement in negative behaviors (e.g., drug use and crime) occurred during the residential program and stabilized during the supported housing program, while improvement in prosocial behaviors (e.g., psychological functioning and employment) was incremental and continuous over the course of both programs. Those who partici pated in the TC-oriented supported housing program demonstrated significantly better outcomes than those who did not. These findings provide preliminary evidence for the effectiveness of a TC-oriented supported housing program as an aftercare strategy for homeless MICA clients following residential treatment.

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.

Measuring Offender Progress in Treatment Using the Client Assessment Inventory

The accurate and reliable assessment of client psychological and cognitive change during correctional substance abuse treatment has gained increasing importance during the past decade as criminal justice systems seek to evaluate and understand those treatment elements associated with long-term change. The Client Assessment Inventory (CAI) is a self-report instrument for measuring client change during treatment across 14 cognitive and behavioral domains. The reliability and internal consistency of the CAI, as adapted for use in criminal justice settings, were examined with data gathered from 1,170 offenders. The research addressed the utility of the CAI for different subpopulations of offenders (e.g., race/ethnicity, gender) across a variety of correctional treatment settings. Overall, the data support the use of the CAI as a consistent, reliable, and easily administered instrument for measuring client performance and progress in treatment in both therapeutic community (TC) and non-TC correctional treatment settings.

Adherence to scheduled sessions in a randomized field trial of case management: The criminal justice–drug abuse treatment studies transitional case management study.

The Transitional Case Management (TCM) study, one of the projects of the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative, was a multi-site randomized test of whether a strengths-based case management intervention provided during an inmate’s transition from incarceration to the community increases participation in community substance abuse treatment, enhances access to needed social services, and improves drug use and crime outcomes. As in many intervention studies, TCM experienced a relatively large percentage of treatment-group participants who attended few or no scheduled sessions. The paper discusses issues with regard to participation in community case management sessions, examines patterns of session attendance among TCM participants, and analyzes client and case manager characteristics that are associated with number of sessions attended and with patterns of attendance. The average number of sessions (out of 12) attended was 5.7. Few client or case manager characteristics were found to be significantly related to session attendance. Clinical and research implications of the findings and of adherence in case management generally are discussed.

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.

Modified therapeutic community aftercare for clients triply diagnosed with HIV/AIDS and co-occurring mental and substance use disorders

This clinical trial evaluated a modified therapeutic community aftercare (MTC-A) program for a population triply diagnosed with HIV/AIDS, a substance use disorder, and a mental disorder. After six months of MTC residential treatment (MTC-R), subjects were randomly assigned to MTC-A (n=42) or to standard aftercare (C; n=34). Follow-up interviews at six and 12 months assessed eight outcome domains and adherence to prescribed HIV medication. A propensity model was used to re-balance the retrieved sample. At the six-month follow-up, High stratum MTC-A clients (those with greater psychological functioning and stable physical health at baseline) had greater improvement overall and for substance use and mental health than C clients in the same stratum. In contrast, C clients in the Low/Medium stratum (those with poorer psychological functioning and improved physical health) had more favorable outcomes overall and for substance use than their MTC-A counterparts; however, this stratum was not re-balanced effectively. Differences in HIV medication adherence were not detected. Clients with greater psychological functioning and stable health at treatment entry benefit more from the MTC-A program. In view of the potentially progressive nature of HIV, measuring physical and mental health during treatment and controlling for changes could be important in future research.