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Hindawi Publishing Corporatione Scienti�c World �ournalVolume 2013, Article ID 427817, 22 pageshttp://dx.doi.org/10.1155/2013/427817

Review ArticleTherapeutic Communities for Addictions: A Review ofTheir Effectiveness from a Recovery-Oriented Perspective

Wouter Vanderplasschen,1 Kathy Colpaert,1 Mieke Autrique,1 Richard Charles Rapp,2

Steve Pearce,3 Eric Broekaert,1 and Stijn Vandevelde4

1 Department of Orthopedagogics, Ghent University, H. Dunantlaan 2, 9000 Ghent, Belgium2Boonsho School of Medicine, Center for Interventions, Treatment and Addictions Research (CITAR), Wright State University,3640 Colonel Glenn Highway, Dayton, OH 45435, USA

3Oxfordshire Complex Needs Service, Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust, Manzil Way,Oxford OX4 1XE, UK

4 Faculty of Education, Health and Social Work, University College Ghent, 9000 Ghent, Belgium

Correspondence should be addressed to Wouter Vanderplasschen; [email protected]

Received 28 October 2012; Accepted 9 December 2012

Academic Editors: V. Di Michele, S. M. Dursun, and T. Shioiri

Copyright © 2013 Wouter Vanderplasschen et al. is is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

erapeutic communities (TCs) for addictions are drug-free environments in which people with addictive problems live togetherin an organized and structured way to promote change toward recovery and reinsertion in society. Despite a long research traditionin TCs, the evidence base for the effectiveness of TCs is limited according to available reviews. Since most of these studies applieda selective focus, we made a comprehensive systematic review of all controlled studies that compared the effectiveness of TCs foraddictions with that of a control condition. e focus of this paper is on recovery, including attention for various life domains anda longitudinal scope. We searched the following databases: ISI Web of Knowledge (WoS), PubMed, and DrugScope. Our searchstrategy revealed 997 hits. Eventually, 30 publications were selected for this paper, which were based on 16 original studies. Twoout of three studies showed signi�cantly better substance use and legal outcomes among TC participants, and �ve studies foundsuperior employment and psychological functioning. Length of stay in treatment and participation in subsequent aercare wereconsistent predictors of recovery status. We conclude that TCs can promote change regarding various outcome categories. Sincerecovering addicts oen cycle between abstinence and relapse, a continuing care approach is advisable, including assessment ofmultiple and subjective outcome indicators.

1. Introduction

Drug addiction is a complex mental health problem thatis oen associated with difficulties in various life domainssuch as unemployment, homelessness, relational con�icts,problems with the courts, and psychiatric comorbidity [1, 2].While some of these problems certainly evolve from theabuse of substances, many eventual addicts suffer from theseproblems prior to the onset of their drug use [3]. In bothcases, drug addiction has generally been treated as an acutecondition during brief episodes of residential care or severalmonths of outpatient treatment, where the primary if not

exclusive focus has been on abstinence to the exclusion ofother concerns [4]. In contrast, addiction is increasinglyregarded as a chronic relapsing disorder where recovery ispossible [5], but oen the one that requires intensive oreven multiple treatment episodes and/or strong personalor community resources. A continuing care approach isneeded to initiate and maintain recovery [6, 7]. e recov-ery movement focuses on individuals’ perceived needs andobjectives and sees abstinence as a potential resource, but notas a prerequisite, for recovery [8–10]. A recovery-orientedapproach in addiction research implies attention for theevolutions on various life domains and individuals’ subjective

2 e Scienti�c World �ournal

well being aswell as the adoption of a longitudinal perspectiveto understand the complexity of individuals’ substance usecareers and recovery processes [11].

A wide range of treatment and support services are avail-able for persons with alcohol or drug addiction problems:detox programs, drug-free outpatient treatment, methadonemaintenance therapy, long-term residential treatment pro-grams, and harm reduction services. erapeutic commu-nities (TCs) for addictions, also called drug-free or conceptTCs, aim at the reinsertion into society of former drugaddicts and were one of the �rst specialized treatment ini-tiatives for individuals with addiction problems, that evolvedoutside—and oen in reaction to—the traditional mentalhealth care. e TC history dates back to Synanon, a self-supporting community of ex-addicts founded in 1958 inSanta Monica (California) [12]. A TC can be de�ned as“a drug-free environment in which people with addictiveproblems live together in an organized and structured way topromote change toward a drug-free life in the outside society”[13]. Until the mid-1980s, TCs had a predominant positionin most Western addiction treatment systems, but due tothe drug and HIV epidemic larger scale harm reductioninitiatives (e.g., methadone maintenance, needle exchangeprograms) became the central focus of most West Europeandrug policies. Despite the long-standing and worldwideavailability of TC treatment, TCs were criticized for theirlimited coverage of drug addicts, the high costs of long-termresidential treatment, and the lack of evidence of effectivenessresulting from randomized controlled trials. Moreover, highdrop-out and relapse rates, altered client expectations andsocial norms and criticism on the impact of lengthy stays inclosed communities further questioned the appropriatenessof TC treatment around the turn of the century [14].

Although outpatient, medically-assisted (substitution)therapy is currently the most common addiction treatmentmodality [15, 16], one out of three clients in the EuropeanUnion is engaging in other types of treatment, includingtherapeutic communities [17]. Recovery-oriented treatmentin TCs starts from the widely accepted concept “communityas a method” [18] and has been implemented on all conti-nents. e standard TC model has been modi�ed to addressthe needs of speci�c populations (e.g., women with children,persons with comorbid psychiatric disorders) or new phe-nomena (e.g., TCs in prisons, methadone substitution duringTC treatment) in the so-called modi�ed TCs (MTC) [19].e TCmethod and objectives match well with the emergingrecovery movement, since TC treatment can be regardedas an educational process where individuals are supportedon their personal journey towards recovery and a drug-freelifestyle and to gain back control over their own lives [20].

Despite a long research tradition in TCs [21, 22], the evi-dence base for the effectiveness of TCs is limited according tothe prevailing Cochrane hierarchy of scienti�c evidence [23].Available reviews have been biased by a selective focus onsome types of TCs or study designs and a predominant focuson drug abstinence.e frequently cited Cochrane review bySmith and colleagues [23] only included randomized trials,while random group allocation appeared to be either notfeasible (i.e., signi�cantly higher drop-out among controls)

or advisable (i.e., motivation and self-selection are consideredto be crucial ingredients of the treatment process) in severalstudies [24, 25]. Consequently, this meta-analysis includedsome studies without true randomization and excluded alarge number of good quality quasi-experimental studies. Arecent review by Malivert and colleagues [26] le out studieson prison TCs, while this type of modi�ed TC has been themost frequently studied TC model during the last decade.Moreover, abstinence and treatment completionwere the soleoutcome measures in this study. Finally, the meta-analysis byLees and colleagues [27] can be regarded as outdated, as itdoes not include any published study since 1999.

Since sound scienti�c evidence is needed to informservice users, treatment providers, and policy makers aboutTCs’ potential to promote recovery, the aim of this paper isto review the effectiveness of TCs for addictions, based ona comprehensive systematic review of available randomizedand nonrandomized controlled studies. e paper is limitedto studies with a controlled design, as these are robuststudy designs that generate a high level of evidence. Also,nonrandomized studies were included, since the numberof randomized studies was very small (𝑛𝑛 𝑛 𝑛) and truerandomization was compromised in several studies. Giventhe focus on recovery, a range of outcome measures—apartfrom abstinence—will be evaluated and a long-term outcomeperspective will be applied, including an assessment of thein�uence of aercare or continuing support.

2. Methods

is narrative review focuses on controlled studies (random-ized trials as well as quasi-experimental designs) of thera-peutic communities for addictions. We opted for a narrativereview instead of a meta-analysis, given the heterogeneity ofthe study methodologies and the variety in data reporting.Studies were eligible if they met the following inclusioncriteria.

(i) Intervention: therapeutic communities for the treat-ment of drug addiction that are long-term hierar-chically structured (residential) educational environ-ments, where former drug users live together andwork towards recovery, and which are based on self-help and mutual help principles [12, 21].

(ii) Target population: adults addicted to illegal drugs(mostly heroin, cocaine, or amphetamines), oenin combination with an addiction to other (legal)substances (e.g., alcohol, prescription drugs). Studiesincluding persons with comorbid psychiatric disor-ders were eligible, if all study participants had a drugaddiction.

(iii) Outcome measures: at least one of the follow-ing (nonexhaustive) list of outcome measures wasreported: substance use (illicit drug use, alcohol use),length of stay in treatment (retention, treatmentcompletion/drop-out), employment status, criminalinvolvement, health and well being, family relations,quality of life, treatment status, mortality, and soforth. Objective (describing the actual situation) and

e Scienti�c World Journal 3

subjective (indicating individuals’ personal perspec-tive) indicators were considered, as well as self-report measures, biological markers, and administra-tive data.

(iv) Study design: randomized controlled trials and quasi-experimental studies that have compared prospec-tively residents that followed TC treatment with acontrol group that was treated in a usual care setting(“treatment as usual”/standard of care) or anothertype of TC (e.g., shorter program/day TC) or with acontrol group out of treatment (e.g., in prison/waitlistcontrols). Studies needed to report �ndings on TCoutcomes separately from these of other types ofinterventions (e.g., aercare).

Available reviews and meta-analyses were not included,but all studies selected for the reviews were screened basedon the aforementioned inclusion criteria. Studies that did notfocus on TC treatment, but on another type of residentialcare, were excluded from the paper. If several publicationsconcerned the same baseline sample and study design, thesepublications were regarded as one single study.

2.1. Search Strategy. We searched the following databases:ISI Web of Knowledge (WoS), PubMed, and DrugScope,up to December 31, 2011. ere were no language, coun-try, or publication year restrictions. Search strategies weredeveloped for each database, based on the search strategydeveloped for ISI Web of Knowledge, but were revisedaccordingly to take into account differences in controlledvocabulary and syntax rules. e key words we searched forwere “therapeutic communit∗” AND “drug∗ or addict∗ ordependen∗ or substance use” AND “outcome∗ or evaluationor follow-up or effectiveness.” e reference lists of retrievedstudies and of available reviews were checked for relevantstudies. In addition, the index of the International Journalof erapeutic Communities, a specialized peer-reviewedjournal on therapeutic communities and other supportiveorganisations, was screened for relevant publications.

Our search strategy revealed 997 hits, which resulted ina �rst selection of 185 records, based on title and abstract(see Figure 1). orough analysis of these abstracts bytwo independent reviewers (Mieke Autrique and WouterVanderplasschen) led to the selection of 46 studies.

In addition to the database search, conference abstracts ofEuropean Federation of erapeutic Communities (EFTC),World Federation of erapeutic Communities (WFTC),and European Working Group on Drugs Oriented Research(EWODOR) conferences and the grey literature werescanned for relevant (un)published studies.Wemade a searchof the registry of ongoing clinical trials to identify anyongoing RCTs. In case a publication could not be trackedthrough the Ghent University online library system, thestudy authors were contacted for a copy of the originalmanuscript. Finally, TC experts in various countries as wellas the European Monitoring Centre for Drugs and DrugAddiction (EMCDDA) national focal points were contactedto retrieve additional (un)published or ongoing studies thathave assessed the effectiveness of TCs for addictions.

2.2. Study Selection. In total, 46 controlled studies wereidenti�ed (28 based on the previously mentioned searchstrategy and 18 additional titles were selected based on thereference lists of selected studies and available reviews).Aer reading the full texts of these articles, 16 studies wereexcluded, because only in-treatment outcomes were reported(𝑛𝑛 𝑛 𝑛), because the treatment provided was not in line withtheTCde�nitionwe put forward (𝑛𝑛 𝑛 𝑛), or because the studydesign was deemed not a controlled design (𝑛𝑛 𝑛 𝑛). Fourstudies were excluded as they concerned secondary analysesof previously published data, usually with a focus on a speci�csubsample. Two studies did not compare TC treatment witha control intervention but rather compared outcomes relatedto speci�c client characteristics.

2.3. Data Extraction and Analysis. Two reviewers (MiekeAutrique and Wouter Vanderplasschen) extracted data onthe characteristics and results from the selected studies intoa large summary table (cf. Table 1). e following studycharacteristics were extracted: (1) author, country (state), andyear of publication; (2) type of study design and timing offollow-up measurements; (3) inclusion criteria and charac-teristics of the study participants + attrition rates at follow-up; (4) type of TC (including length of treatment) and typeof control condition; and (5) outcome categories: retentionand completion rates, substance use outcomes (drug andalcohol use), criminal involvement, employment, and otheroutcomes like health status, housing situation, and a columnincluding determinants/correlates of abstinence/retention.Findings from studies including multiple follow-up assess-ments were grouped and numbered accordingly (cf. Table 1).We compared reported outcomes in various categories at allreported follow-up moments post treatment (cf. Table 2.).In this summary table, “+” indicates a signi�cant differenceregarding the outcome category in favor of the experimentalcondition, while “-” indicates a signi�cant difference in favorof the control group. “�” means that no signi�cant betweengroup differences were reported; alternatively text can berephrased as follows: that no signi�cant differences werereported between the experimental and the control group.

3. Results

Based on our review of controlled studies of TC effectiveness,we identi�ed 30 publications that included a longitudinalevaluation of TCs for addictions and applied a prospectivecontrolled study design (cf. Table 1). ese 30 publicationsare based on—in total—16 original studies, since severalarticles referred to the same (large) study and/or to variousmeasurements regarding one single study (e.g., the Delawarestudy (no. 7) by Inciardi and colleagues [28–32]; the Amityprison study (no. 8) by Prendergast and colleagues [33–35]). orough methodological screening revealed that only�ve studies could be regarded as truly randomized (cf.Table 1), since in most studies the random group allocationprocess was compromised at some point [25, 36] or wasnot possible/advisable at all [24, 37, 38]. e methodologicalquality of the studies varied but was oen rather poor dueto high attrition rates, lack of objective veri�cation of study

4 e Scienti�c �orld �ournal

Records identified through database searches

WoS: 968

PubMed: 5 (add. records)

DrugScope: 24 (add. records)

Records screened based on title and abstract

WoS: 133



Full texts assessed for eligibility

WoS: 24



Reference lists: 18

Controlled studies

Records added based

on search of

reference lists

Records

excluded

Eligible studies Excluded studies (

Not a controlled design:

No comparison of two interventions:

Only in-treatment outcomes:

Intervention TC treatment:

Secondary analysis of previously published data:

F 1: Flowchart of the search process and number of studies retained/excluded in each phase.

�ndings, and a focus on one single study site (cf. Table 1).e oldest controlled studies date back to the beginningof the 1980s [39–41]. e bulk of studies has been carriedout/published in the 1990s. All controlled studies have beenperformed in the United States. Despite a growing researchtradition in Europe, Australia, and South America, onlyobservational uncontrolled studies have been carried out onthese continents.

e follow-up period in most controlled studies isbetween 6 and 24 months, and only three studies have fol-lowed participants for more than 36months. Study outcomesmay vary according to the follow-up moment [24, 25, 33],

but usually the magnitude of the difference(s) between theexperimental and control group diminished over time (cf.Table 2). Overall, great within-group reductions in prob-lem severity were observed between baseline and follow-up assessments, in particular regarding drug use, criminalinvolvement, and employment. e two outcome measuresthat were assessed in most studies are “substance use” and“criminal involvement.” All included studies reported at leastone outcome measure in one of both categories. Eight outof 13 (note that this number is lower than 16, as not allstudies reported outcomes concerning all categories) studiesreported at least one positive signi�cant difference between

e Scienti�c �orld �ournal 5

the TC and control group regarding legal outcomes at theone-year follow-up, while 9/14 studies found signi�cantlybetter substance use outcomes among the TC group at thattime (cf. Table 2). All studies included multiple outcomeindicators (also within one category), but only one studysucceeded to �nd several signi�cant, positive outcomesregarding most legal outcome measures (i.e., reincarcerationrate, days to �rst illegal activity/incarceration, and length ofprison sentence) [34].Most studies found only one signi�cantbetween group difference per category (e.g., time to drugrelapse), while other outcome indicators within this categorydid not differ between groups (cf. Table 1). Signi�cantlybetter outcomes in one category (e.g., substance use, criminalinvolvement) are not necessarily accompanied by improvedoutcomes on other domains (e.g., employment, psycholog-ical health). Only four studies found signi�cant differencesregarding three or more outcome categories [24, 32, 42, 43].

3.1. Treatment Retention, Health, and Social Functioning. Asopposed to all other outcome categories, TC participantsscored worse in comparison with controls on treatmentretention/completion. Only two studies showed higher reten-tion rates for the TC group, while three studies foundsigni�cantly worse completion rates among TC-participants,and six studies found non-signi�cant between group differ-ences, mostly in favor of the control condition (cf. Table 1).Substantial drop-out has been observed in most long-termTC programs, especially in the early phases of treatment [48].Studies that have compared longer and shorter TC programsusually found lower completion rates in longer and moreintensive programs [38, 51].

Five out of six studies that have reported employmentoutcomes found signi�cantly better employment rates amongTC participants. Also, �ve studies (out of 7) showed superioroutcomes on psychological symptoms, as compared withcontrols. Other outcomes that were studied are risk behavior(𝑛𝑛 𝑛 𝑛) and family and social relations (𝑛𝑛 𝑛 𝑛), which werefound to be better in two studies [32, 48].

3.2. Substance Use Outcomes. Although TC participants hadat some point posttreatment better substance use outcomesthan controls in 10 studies, substance use levels variedgreatly and overall, between 25% and 55% of the respondentsrelapsed to drug use aer 12 to 18 months. Some studiesfound very low initial relapse rates (e.g., 4% [38], 9% [42] and15% [43]), while others foundmuch higher relapse rates (e.g.,53% [34] and 69% [29]). Usually, time to relapse was longeramongTCparticipants [52].One of the few controlled studiesthat followed prison TC-participants up to three years aertheir release found a relapse rate of 77% in the TC and 94% inthe control condition [29]. Lower relapse rates were usuallyassociated with longer treatment exposure (length of stay intreatment/retention) [24, 31, 39, 41, 52] and participation insubsequent treatment or aercare [32, 35]. Treatment drop-out and relapse aer treatment were predicted in at least twostudies by the severity of substance use at baseline [28, 38].

3.3. Legal Outcomes. emajority of studies found a positiveimpact of TC treatment on diverse legal outcomes, such as

recidivism, rearrest, and reincarceration. Recidivism rates(self-reported criminal involvement) of TC participants aerone year are usually around 40%–50% [19, 31], as well asrearrest rates [29, 44], although one study reported a rearrestrate of only 17% 18 months aer the start of TC treatment[42]. Reincarceration rates 12 to 18 months aer releaseare between 30% and 55% in most studies, although Sacksand colleagues have reported clearly lower rates (19% and9%, resp.) in two studies [19, 36]. Long-term follow-upmeasurements of prison TC participants indicate rearrestrates of 63% aer three years [29] and 80% aer �ve years [44]and reincarceration rates of over 70% aer 5 years [33, 44].Again, time to reincarceration was lower in the TC groupand treatment completion and/or time in treatment predictedabsence of recidivism [28, 31, 33, 36, 42, 49]. Treatmentcompletionwas found to be associatedwith (older) age, single(instead of poly) drug dependence and being on parole [42].

3.4. Long-Term Outcomes and Outcome Predictors. Six con-trolled studies have investigated the outcomes of TC partici-pants in comparisonwith controls beyond a period of 12 to 18months (cf. Table 2). Five of these studies show signi�cantlybetter legal outcomes in favor of the TC group, while onlythree studies could demonstrate signi�cantly lower levelsof illegal drug use two years aer TC treatment. One ofthese studies [40] found a higher prevalence of alcoholproblems among TC participants at the two-year follow-up,when compared with controls who only followed a shortdetoxi�cation period.

Several studies have identi�ed correlates of relapse andrecidivism aer TC treatment. Participation in aercare[28, 35, 44], posttreatment employment [37], and older age[28, 33] were found to be the most common predictorsof abstinence and absence of rearrest (cf. Table 1). eeffectiveness of completing treatment was shown in severalstudies, as TC + aercare completers had better outcomesthan aercare drop-outs, who had in turn better outcomesthan TC completers and TC drop-outs [33, 35]. Martin andcolleagues [32] even found no differences between inmateswho followed in-prison TC treatment without subsequentaercare and controls who received usual work release.Relapse to drug use is oen associated with reoffending andreincarceration [46].

3.5. Type of Controls and TC Modalities. Eleven studies havecompared TC treatment with some form of usual care (e.g.,case management, standard treatment, and probation), and�ve studies compared one type of TC with another formof TC treatment (modi�ed versus standard TCs, or shortversus long TC programs). In the latter case, the longest/mostcomprehensive TC program was regarded as the experi-mental condition, while the shorter/least intensive programwas seen as the control condition. Only three comparisonsof longer and shorter TC programs yielded signi�cantlybetter substance use outcomes at the �rst follow-up moment[25, 41, 42], while overall few signi�cant differences wereobserved in comparison with other TC modalities. Twostudies found better employment outcomes compared withlower intensity TC models, and one study found fewer

6 �e Scienti�c �orld �ournal

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5priso

nTC

s(𝑛𝑛𝑛𝑛𝑛𝑛)

Leng

thvarie

dfro

m9(𝑛𝑛𝑛𝑛)

to12

(𝑛𝑛𝑛𝑛)

and16

mon

ths(𝑛𝑛𝑛𝑛);

controls(𝑛𝑛𝑛𝑛𝑛𝑛):

3othertypes

ofdrug

Tx(drug

education,

outpatient

Tx,

self-helpgrou

ps)

No≠in

numbero

fpo

s.drug

tests

(35

versus

38%)

Lower

reincarc

andrearrest

rates,respec-

tively

30and

24%versus

41and34%∗

Reincarc.and

rearrest

respectiv

ely1.6∗

and1.5∗

times

high

eram

ong

controls

Highere

mploy.:39.2

versus

25.9%∗∗

∗

Reincarc.predicted

bypo

st-release

employmentstatus

Drugrelapse

predictedby

age

andem

ployment

(older

and

employed

person

slesslik

elyto

relapse)

(5)S

ullivan

etal.,

2007

(Colorado,

USA

)[46]

Prospective

rand

omized

controlledstu

dydesig

nOutcomes

12mon

ths

post-

release

139male

inmates

with

substanceu

seandother

psychiatric

disorders

FU:75%

(82

versus

69%)

Priso

nMTC


12mon

thprogram

Con

trols:

stand

ard

mentalh

ealth

Txin

priso

n(𝑛𝑛𝑛𝑛𝑛)

Rateso

fany

substance

use:31

versus

56%∗∗;any

illicitdrug

use:25

versus

44%∗;alcoh

olintox.:21

versus

39%∗

Timeto

relapse:3.7

versus

2.6

mon

ths∗

Sign

.associatio

nbetweenrelapse

andcommitting

new(non

drug)

offences

IncreasedORfor

reoff

ending

(4.2∗)

andreincarc.(5.8∗)

amon

gperson

swho

relapsed

insubstanceu

se

(5)S

acks

etal.,2004

(Colorado,USA

)[36]Pr

ospective

controlledstu

dydesig

n(notrue

rand

omisa

tion,

since

51subjects

moved

from

one

cond

ition

toanother)

Outcomes

12mon

thsa

er

priso

nrelease

185male

inmates

with

substanceu

seandother

psychiatric

disorders

FU:75%

(82

versus

69%)

Priso

nMTC


12mon

ths

Con

trols:

stand

ard

mentalh

ealth

Tx(𝑛𝑛𝑛𝑛𝑛)

Lower

reincarc.

rates:9versus

33%∗∗;no≠

regardingother

crim

inal

outcom

es

MTC

aercare

participantshad

superio

routcomes

regardingrateso

freincarc.∗,crim

.activ

ity∗and

drug-related

crim

activ

ity∗compared

with

controls

TimeinTx

predictedabsence

ofreincarc∗∗

and

crim

activ

ity∗∗

8 �e Scienti�c World �ournal

T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(6)M

orraletal.,2004

(Los

Angele

s,USA

)[47]

Prospective

controlledstu

dydesig

n(cases

assig

nedby

prob

ation)

Outcomes

12mon

thsa

erstart

TCprogram

449adolescent

prob

ationers

with

substance

abusep

roblem

sFU

:90.4%

aer

3mon

ths

FU:91.3%

aer

6mon

ths

FU:90.8%

aer

12mon

ths

MTC

inpriso

n(Pho

enix

Academ

y)(𝑛𝑛𝑛𝑛𝑛𝑛)

9mon

thprogram

Con

trols(𝑛𝑛𝑛𝑛𝑛𝑛):

alternative

prob

ation

disposition

(res.

grou

pho

mes)

No≠in

program

retention

Improved

substanceu

seou

tcom

eson

substance

prob

lem

index∗,

density

index∗,and

involvem

ent

scale∗

Greater,

nonsign.

declineso

nvario

usmeasureso

fcrim

involvem

ent

Greater

redu

ctionof

somatic∗∗

and

anxiety∗

symptom

s+sig

n.larger

redu

ctions

inpsycho

logical

symptom

sbetween3and

12mon

thFU

(7)Inciardietal.,

2004

(Delaw

are,

USA

)[28]

Prospective

controlledstu

dydesig

n(group

assig

nmentb

ycorrectio

nalstaff)

Outcomes

42and

60mon

thsa

er

baselin

e

690male

inmates

with

substancea

buse

prob

lems,

eligibleforw

ork

release

FU:69.8%

aer

48mon

ths

FU:63.8%

aer

60mon

ths

Work-release

(transitional)TC


6mon

thprogram

Con

trols:

stand

ard

workrelease,

with

outT

x(𝑛𝑛𝑛𝑛𝑛𝑛)

TC participation

stron

gest

predictoro

fdrug-fr

eesta

tusa

er4

2(O

R4.49

∗∗∗)

and60

mon

ths(OR

3.54

∗∗∗)

TCparticipation

stron

gest

predictoro

fabsenceo

frearresta

er42

(OR1.71

∗∗)a

nd60

mon

ths(OR

1.61

∗)

Older

age

predicted

drug-fr

ee∗∗

andno

rearreststa

tus∗∗∗,

whilefre

quency

ofpriord

ruguse

predictedrelapse∗

∗

aer

48mon

ths

Noprevious

Txexperie

nce

predictedrelapse

aer

60mon

ths,

whileoldera

ge∗

andbeingfemale∗

predictedno

rearrest

TCcompletion

associated

with

norearrestandbeing

drug

freea

er4

2and60

mon

ths,

with

superio

rou

tcom

esfor

person

swho

attend

edadditio

nal

aercare


T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(7)M

artin

etal.,1999

(Delaw

are,USA

)[29]Pr

ospective

controlledstu

dydesig

n(partia

lrand

omization,

since

KEY

program

autom.

follo

wed

byCR

EST)

Outcomes

6,18,

and42

mon

ths

aer

baselin

e(i.e.,

1and3yearsa

er

TCperio

d)

428inmates

with

drug

abuse

prob

lems

FU:app

rox.80%

TransitionalT

C(C

REST

)(𝑛𝑛𝑛𝑛𝑛𝑛)

6mon

thprogram

Con

trols:

priso

nTC

(KEY

)(𝑛𝑛𝑛𝑛𝑛)

12mon

thprogram

Priso

nTC

+transitionalT

C(𝑛𝑛𝑛𝑛𝑛)

Regu

larw

ork

release(𝑛𝑛𝑛𝑛𝑛𝑛)

18mon

thou

tcom

es

31%

drug-fr

eeversus

16%∗

in work-release

grou

p(versus

47%in

KEY+

CRES

Tgrou

p)

57%no

trearreste

dversus

46%∗in

work-release

grou

p(versus

77%in

KEY+

CRES

Tgrou

p)

Whilegreater

expo

sure

toTC

Txledto

bette

rou

tcom

esa

er1

year,at3

yearsa

er

dischargen

o≠

werefou

ndbetweenvario

usTC

mod

alities

CRES

Tdrop

-outs

aslik

elyto

berearreste

das

work-release

grou

p,bu

tCRE

STcompleters∗∗+

CRES

T-completers

who

follo

wed

subsequent

aercare∗∗

∗were

leastlikely

tobe

arreste

dCR

ESTdrop

-outs

morelikely

tobe

drug

freethan

work-release

grou

p∗,but

CRES

Tcompleters∗∗+

CRES

T-completers

who

follo

wed

subsequent

aercare∗∗

∗even

morelikely

tobe

drug

free

42mon

thou

tcom

es

ORforb

eing

drug

free8

.2tim

eshigh

erin

CRES

T-grou

p∗∗,7.4

times

inKE

Y-grou

p∗∗,and

6.7tim

esin

KEY-CR

EST

grou

p∗compared

with

work

releaseg

roup

;23%

drug-fr

eeversus

6%∗in

work-release

grou

p

37%no

trearreste

dversus

30%in

work-release

grou

pa

er42

mon

ths

(7)L

ockw

oodetal.,

1997

(Delaw

are,

USA

)[30]

Prospective

controlledstu

dydesig

nOutcomes

6mon

ths

post-

release

483inmates

with

histo

ryof

substancea

buse

FU:app

rox.80%

TransitionalT

C(C

REST


6mon

thprogram

Con

trols:

priso

nTC

(KEY

)(𝑛𝑛𝑛𝑛𝑛)

12mon

thprogram

Priso

nTC

+transitionalT


Regu

larw

ork


87%

drug-fr

ee,

versus

71%in

KEY,73.7%

inwork

releasea

nd93.3%in

KEY-CR

EST

grou

p

86.5%no

arrest,

versus

75%in

KEY,59.9%in

workreleasea

nd97.1%in

KEY-CR

EST

grou

p


T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(7)N

ielse

netal.,1996

(Delaw

are,USA

)[31]

Prospective

controlledstu

dydesig

n(Q

ES)

Outcomes

aer

6and18

mon

ths

689inmates

with

histo

ryof

substancea

buse

FU:77versus

72.6%a

er6

mon

ths

FU:58.5versus

36.7%a

er18

mon

ths

TransitionalT

C(C

REST


6mon

thprogram

Con

trols:

conventio

nalw

ork


Sign

.low

errelapsea

er6

(16.2versus

62.2)∗∗∗

and

18mon

ths

(51.7versus

79%)∗∗∗

Sign

.low

errecidivism

aer

6(14.7versus

35.4)∗∗∗

and18

mon

ths(38.2

versus

63%)∗∗∗

Age,race,and

gend

erdo

not

affecto

utcomes,

butlengthof

time

inprogram

redu

cedrelapse

andrecidivism

rates(ns)

Program

completion

associated

with

fewer

relapse∗

∗∗

aer

6andfewer

recidivism

aer

6∗∗∗

and18

mon

ths∗

(7)M

artin

etal.,1995

(Delaw

are,USA

)[32]

Prospective

controlledstu

dydesig

n(Q

ES)

Outcomes

6mon

thsa

er

release

483inmates

with

histo

ryof

substancea

buse

FU:app

rox.80%

TransitionalT

C(C

REST


6mon

thprogram

Con

trols:

priso

nTC

graduates(KE

Y)(𝑛𝑛𝑛𝑛𝑛)

Priso

nTC

+transitionalT


Regu

larw

ork


Prob

abilityof

beingdrug

freethe

high

est

amon

gCR

EST

(0.84)

∗∗∗and

KEY+

CRES

Tgrou

p(0.94)

∗∗∗

Prob.ofb

eing

arrestfre

ethe

high

estamon

gCR

EST

(0.86)

∗∗∗and

KEY+CR

EST

grou

p(0.97)

∗∗∗

Prob.ofn

olonger

injecting

theh

ighestin

CRES

T(0.97)

∗∗∗and

KEY+CR

EST

grou

p(0.97)

No≠betweenTC

onlyandwork

releaseg

roup

onanyof

theo

utcome

measures

Longer

timein

(sub

sequ

ent)Tx

theb

estp

redictor

ofdrug-fr

ee∗∗

∗and

arrest-

free∗

status

aer

Tx,asw

ellas

participationin

alonger

TCprogram

(8)P

rend

ergastetal.,

2004

(Califo

rnia,U

SA)

[33]

Prospective

rand

omized

controlledstu

dydesig

nOutcomes

5years

aer

release

715male

inmates

with

substancea

buse

prob

lems

FU:81.2%

Amity

priso

nTC


9–12

mon

thprogram

Con

trols:

noTx

cond

ition

(waitlist)


Mon

ths

receivingTx

post-

release:

4.6versus

1.7∗

∗∗

Heavy

drug

usep

astyear:

24.9versus

22.6%

Reincarcerated

with

in5years:

75.7versus

83.4%∗

Daysto

reincarc:809

versus

634∗

∗∗

Stablejobin

past

year:54.8versus

52.3%

Psycho

logic.

distr

ess:31.8

versus

44.6

Reincarc.predicted

byyoun

gera

ge∗

andfewer

mon

ths

inTx

aer

release∗

∗∗

Com

pletionof

TCanda

ercare

predictedabsence

ofreincarc.∗∗

∗


T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(8)P

rend

ergastetal.,

2003

(Califo

rnia,

USA

)[34]

Prospective

rand

omized

controlledstu

dyOutcomes

12mon

thsa

er

release

715male

inmates

with

substancea

buse

prob

lems

FU:74%

Amity

priso

nTC


9–12

mon

thprogram

Con

trols:

noTx

cond

ition

(waitlist)


Longer

time

to�rstdrug

use:77

versus

31days

∗∗∗

No≠in

pos.

drug

tests

(52.9versus

61%)

1year

reincarc.

rate:33.9versus

49.7%∗;m

ore

days

to�rst

illegalact.(138

versus

71days)∗∗∗;no≠

intype

ofarrest;

mored

aysto

�rstincarcer.

(285

versus

243

days)∗∗∗;few

ermon

thsin

priso

n(3

versus

4.7)

∗∗∗

Participationin

Txassociated

with

more

days

toreincarc.

Ae

rcarec

ompleters

hadthelow

est

reincarc

rate+the

longesttim

eto�rst

illegalactiv

ityandto

reincarcerationand

fewer

days

inpriso

nPriso

nTC

drop

-outs

hadthes

hortesttim

eto

SRdrug

use(32

days),follo

wed

byTC

completers(62

days),

aercare

drop

outs

(91days),and

aercare

completers

(184

days)+

more

pos.drug

tests

(8)W

exlere

tal.,1999

(Califo

rnia,U

SA)

[35]

Prospective

rand

omise

dcontrolledstu

dydesig

nOutcomes

12and

24mon

thsa

er

release

715male

inmates

who

volunteeredfor

TCtre

atmentin

priso

nFU

:100%a

er12

mon

ths

FU:36.8%

aer

24mon

ths

Amity

priso

nTC


8–12

mon

thprogram

Con

trols:

noTx

cond

ition

(waitlist)


Lower

reincarc

ratesa

er1

2(33.9versus

49.7%)∗∗∗

and

24mon

ths(43.3

versus

67.1%)∗∗∗

Mored

aysto

reincarc

aer

12(192

versus

172∗)m

onths

ORforreincarc

signlower:

0.52

∗∗∗a

er12

and0.63

∗∗a

er24

mon

ths

Reincarc.rates

sign

lower

aer

12and24

mon

thsa

mon

gTC

+a

ercare

completers,

asop

posedto

person

swho

drop

ped

outp

reviou

slyAe

rcarec

ompletion

positively

relatedto

timetoreincarc.+

thes

trongest

predictoro

fpositive

outcom

es

12 �e Scienti�c World �ournal

T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(9)G

reenwoo

detal.,

2001

(San

Francisco,

USA

)[25]

Prospective

controlledstu

dydesig

n(only

partial

rand

omisa

tion,

since

sign.

drop

-out

amon

gcontrolbeforeT

xsta

rt)

Outcomes

6,12,

and18

mon

ths

aer

admission

261substance

abusersseeking

treatmentat

WaldenHou

seFU

:82.4%

at6

mon

ths

FU:82.7%

at12

mon

ths

FU:82.7%

at18

mon

ths

Resid

entia

lTC


12mon

thprogram

Con

trols:

dayTC

program

(sam

eTC

,but

returned

homea

tthe

endof

thed

ay)(𝑛𝑛𝑛𝑛𝑛𝑛)

Timein

program:

109.8versus

102.7days

Total

abstinence

aer

6(62.6

versus

47%),

12(47.9

versus

49%)

and18

mon

ths(50.4

versus

55.2%)

ORfor

relapsea

t6mon

ths=

3.06

∗,not

sign.

at12

and18

mon

ths

Relapsea

er1

8mon

thsp

redicted

byem

ployment

statusp

riortoTx

start∗∗

∗,injectin

gdrug

use∗

∗and

having

>1sexu

alpartner∗∗

(9)G

uydish

etal.

1999

(San

Francisco,

USA

)[48]

Prospective

controlledstu

dydesig

n(only

partial

rand

omisa

tion,

since

sign.

drop

-out

amon

gcontrolsbefore

Txsta

rt)

Outcomes

at6,

12,and

18mon

ths

188substance

abusersseeking

treatmentat

WaldenHou

sewho

participated

inall3

FU-in

terviews

Resid

entia

lTC


12mon

thprogram

Con

trols:

dayTC

program

(sam

eTC

,but

returned

homea

tthe

end

thed

ay)(𝑛𝑛𝑛𝑛𝑛)

No≠in

timeto

drop

-out

(119.7versus

108.1days)

12mon

thretentionin

dayTC

:17%

versus

9%

Lower

SCL

scores

at6∗

∗,

12∗,and

18∗

mon

ths,lower

BDIscoresa

er

12mon

ths∗,

high

ersocial

supp

ortscores

at18

mon

ths∗;

lower

social

prob

lem

severity(A

SI)∗

Mostchanges

observed

durin

g�rstmon

thso

fTx,

follo

wed

bymaintenance

ofchange

(9)G

uydish

etal.

1998

(San

Francisco,

USA

)[49]

Prospective

controlledstu

dydesig

n(only

partial

rand

omisa

tion)

Outcomes

at6

mon

ths

261substance

abusersstarting

treatmentat

WaldenHou

seFU

:82.4%

at6

mon

ths

Resid

entia

lTC


12mon

thprogram

Con

trols:

dayTC

12mon

thprogram


Tx adherence

aer

6mon

ths:29

versus

34%

indayTC

;TimeinTx

:109.8versus

102.7days

Lower

ASI

severityscores

forsocial∗and

psycho

logical

prob

lems∗∗

Person

swho

stayed

>6mon

thsinTx

hadsig

nlower

legal,alcoho

l,drug

,andsocialseverity

scores

Alcoh

olseverity

redu

cedsig

n.if

person

sstayed>6

mon

thsin

resid

entia

lTC


T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(10)

Nem

esetal.1999

(Washing

ton,

USA

)[42]

Prospective,

rand

omise

dcontrolledstu

dydesig

nOutcomes

18mon

thsa

er

admission

412substance

usersseeking

Txatac

entral

intake

unit

FU:93%

Standard

TC(𝑛𝑛𝑛𝑛𝑛𝑛)

12mon

thprogram

(10mon

ths

inpatie

nt,2

outpatient)

Con

trols:

abbreviatedTC

(𝑛𝑛𝑛𝑛𝑛𝑛):12

mon

thprogram

(6mon

thinpatie

nt,6

mon

thou

tpatient

+extras

ervices)

Com

pletion

rates:33

versus

38%

(ns),and

similartim

ein

Tx(8.2

versus

8.6

mon

ths)

Lower

SRheroin

use:9

versus

15%∗

Lower

rearrest

rates:17

versus

26%∗∗

+longer

timetoarrest

(9.4versus

6.9

mon

ths)∗

Employmentrate

high

erin

stand

ard

TC:72versus

56%∗∗

Lower

heroin

and

cocaineu

selevels+

lower

rearrestrates

amon

gtre

atment

completersv

ersus

noncom

pleters

Positivec

ocaine

tests

were

associated

with

prem

atureT

xdrop

-out

Treatm

ent

completionwas

predictedby

age,

singleh

eroin

depend

ence,and

parolesta

tus

(11)

DeL

eonetal.,

2000

(New

York,

USA

)[24]

Prospective

controlledstu

dydesig

n(Q

ES:

sequ

entia

lgroup

assig

nment)

Outcomes

12and

onaverage2

4mon

thsa

er

baselin

e

342ho

mele

ssmentally

illsubstance

abusers

FU:68%

at12

mon

ths

FU:82%

atlatest

FU

MTC

1for

homele

ssperson


12mon

thprogram

MTC

2:lower

intensity,�exible

program


12mon

thprogram

Con

trols:

treatmentasu

sual


12mon

ths

MTC

2had

lessalcoho

lintox∗

+fewer

illegal

drug

use∗

∗+

used

less

substances

∗∗

than

TAU

No≠

between

MTC

1and

TAU

No≠between

MTC

1or

MTC

2andTA

U

MTC

1∗∗∗

and

MTC

2∗∗∗

more

likely

tobe

employed

than

TAU

No≠between

MTC

1or

MTC

2and

TAUregard.

HIV

risk

behavior

and

psycho

logical

dysfu

nctio

ns

24mon

ths

MTC

2had

lessalcoho

lintox∗

+used

less

substances

∗

compared

with

TAU

No≠

betweenTC

1andTA

U

MTC

1∗and

MTC

2∗∗∗

committed

fewer

crim

esthan

TAU

MTC

1∗∗and

MTC

2∗∗∗

more

likely

tobe

employed

than

TAU

MTC

2hadless

symptom

sof

depressio

n∗∗∗

andanxiety∗

than

TAU

MTC

2im

proved

moreo

nseveral

outcom

esmeasures

than

MTC

1MTC

completers

scored

signbette

rthan

MTC

drop

-outsa

ndTA

U


T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(11)

French

etal.,

1999

(New

York,

USA

)[50]

Prospective

controlledstu

dydesig

n(Q

ES:

sequ

entia

lgroup

assig

nment)

Outcomes

atlast

FU-point

(on

average2

4mon

thsa

er

baselin

e)

342ho

mele

ssmentally

illsubstance

abusers

FU:82%

MTC

forh

omele

ssperson


12mon

thprogram

Con

trols:

treatment

asusual(𝑛𝑛𝑛𝑛𝑛)

No≠regard.

substanceu

seou

tcom

esFewer

crim

inal

activ

ity∗∗

Bette

remploym.

outcom

es(ns)

Lower

scores

onBD

I∗,no≠

regard.other

psycho

logical

symptom

sor

riskbehavior

(12)

Nuttbrock

etal.,

1998

(New

York,

USA

)[38]

Prospective

controlledstu

dydesig

n(Q

ES,as

allocatio

nbased

onavailability+

clientp

reference)

Outcomes

12mon

thsa

erstart

Tx

290ho

mele

ssmen

with

major

mentald

isorder

andhisto

ryof

substancea

buse

FU:not

repo

rted

Mod

i�ed


18mon

thprogram

Con

trols:

2ho

mele

sscommun

ityresid

ences(𝑛𝑛𝑛𝑛𝑛𝑛)

18mon

thprogram

43%sta

yed6

mon

thsin

TC(versus

55%);25%

stayed12

mon

ths

(versus3

7%)

4.1versus

30.1%po

s.urinetests∗

;SR

alcoho

luse:0versus

14.3%∗;SR

mariju

ana

use:2.6

versus

2.9%

;SR

crackuse:

7.7versus

14.2∗

Greater

(ns)

redu

ctions

inpsycho

-patholog

y(depression,

anxiety,

psychiatric

distr

ess)MTC

participation

predictedlower

levelsof

anxiety∗

∗and

bette

rGAF-scores

∗∗

Drop-ou

tae

r6–12

mon

thsin

commun

ityresid

encesw

aspredictedby

substanceu

seseverity∗

(13)

McC

uskere

tal.

1997

(New

England,

USA

)[51]

Prospective

controlledstu

dydesig

n(noreal

rand

omisa

tion,

since

≠interventio

nsat

both

study

sites)

Outcomes

3mon

thsa

er

dischargea

nd18

mon

thsa

er

admission

539drug

abuserse

ntering

resid

entia

lTxat

2sites

FU:86%

aer

18mon

ths

Tradition

alTC

program

(6(𝑛𝑛𝑛𝑛𝑛)

and12

mon

thalternative(𝑛𝑛𝑛𝑛𝑛))

Con

trols:

MTC

program

(relapse

preventio

n)3


and6

mon

th(𝑛𝑛𝑛𝑛𝑛𝑛)

alternatives

Tx completion:

23%in

long

TC,34%

inshorterT

C,31%in

long

MTC

and

56%in

short

MTC

Timetodrug

usen

ot≠

betweenTC

sandthan

MTC

Stronger

effecto

flon

gTC

versus

shortT

Cand

MTC

sregard.

drug

and

alcoho

lseverity(ns)

Stronger

effect

oflong

TCversus

shortT

CandMTC

sregardinglegal

prob

lems

Effecto

fTCon

employm.stro

nger

than

inMTC

∗

Smalleffectso

flong

TCversus

shortT

Cand

MTC

sregard.

otherA

SIdo

mains

e Scienti�c �orld �ournal 15T

1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(13)

McC

uskere

tal.,

1996

(Massachusetts,

USA

)[52]

Prospective

rand

omized

controlledstu

dydesig

nOutcomes

6mon

thsa

erT

x

444drug

abuserse

ntering

oner

esidentia

lTx

facility

FU:74%

Long

MTC


6mon

thprogram

Con

trols:

short

MTC


3mon

thprogram

Program

completion:

30versus

56%in

short

TCprogram

Relapseto

drug

usein

�rstweek

aer

leaving

Tx:33versus

70%∗

Nogrou

p≠

inheroin

orcocaineu

se

Greater

improvem

entin

levelsof

depressio

nam

ongperson

ssta

ying

>80days

inTC

∗∗∗

Leng

thof

stayin

TC∗∗

+program

completion∗

pos.

associated

with

levelsof

precon

templation

Person

sstaying

>80days

inTC

had

lower

drug

use∗

∗∗

(13)

McC

uskere

tal.,

1995

(New

England,

USA

)[53]

Prospective

controlledstu

dydesig

nOutcomes

3–6

mon

thsa

er

discharge

628drug

abuserse

ntering

resid

entia

lTxat

2sites

FU:84%

inTC

versus

74%in

MTC

Tradition

alTC

program

(6(𝑛𝑛𝑛𝑛𝑛)

and12

mon

th(𝑛𝑛𝑛𝑛𝑛)a

lternative)

Con

trols:

MTC

3(𝑛𝑛𝑛𝑛𝑛𝑛)

and6

mon

thprogram


40day

retention:

respectiv

ely,

70,85,73,

and72%;T

xcompletion:

respectiv

ely,

33,21,56,

30%(ns≠

in4grou

ps)

Relapse:50%

inTC

versus

44%in

MTC

No≠in

numbero

fdays

ofdrug

use

(14)

Hartm

annetal.

1997

(Miss

ouri,

USA

)[43]

Con

trolledstu

dydesig

n(Q

ES,

self-selectionfor

exp.interventio

n)Outcomes

atleast

5mon

thsa

er

release

286male

offenderswith

ahisto

ryof

substancea

buse

Noinform

ation

onFU

-rate

Priso

nTC

graduates


Noinform

ationon

program

leng

thCon

trols:

comparis

ongrou

pof

eligibleperson

swho

didno

tatte

ndpriso

nTC


Nosubstance

abuse:67.4

versus

62%

(ns)

Noarrest:

85.4

versus

72%∗∗

Reincarc.:16.4

versus

27.6∗

(15)

Baleetal.,1984

(Califo

rnia,U

SA)

[39]

Prospective

controlledstu

dydesig

n(only

partial

rand

omization

duetosubstantial

drop

-out

aer

grou

pallocatio

n)Outcomes

aer

2years

363male

veterans

addicted

toheroin

enterin

gwith

draw

alTx

FU:95.6%

3TC

s(𝑛𝑛𝑛𝑛𝑛𝑛):

stand

ardTC

(𝑛𝑛𝑛𝑛𝑛)+

two

MTC

s(𝑛𝑛𝑛𝑛𝑛

and

𝑛𝑛𝑛𝑛𝑛)

6mon

thprograms

Con

trols:

5-day

with

draw

alTx


MeanTIP

longer

inTC

1(10.4

weeks)a

ndTC

3(11.5

weeks)∗

than

inTC

2(6.0

weeks)

Noheroin

use:40,48.1,

and35.4%

versus

33.3%

ofcontrols;

Noother

illegaldrug

use:40,41.6,

and53.3%∗

versus

39.3%

ofcontrols

Morea

lcoh

olprob

lems:40,

47.3∗∗

and

30.8%versus

22.4%of

controls

Noconvictio

n:44

∗,32.5and

59.5%∗∗

versus

31.3%of

controls

Employed/atte

nding

scho

ol:48∗,46.8and

51.9%∗∗

versus

34%

ofcontrols

Mortality:1.7%

inTC

sversus

6.6%

amon

gcontrols

e3

TCsd

iffered

largely

onprogram

characteris

tics

Heroinuse+

other

major

outcom

essig

n.bette

ramon

gsubjectssta

ying

longer

inTx


T1:Con

tinued.

Authors

Stud

ydesig

n+

measurement(s

)Participants

Interventio

n+

comparis

ongrou

pOutcomem

easures

Correlateso

frelapse/abstinence

Retention

Substanceu

seCr

imactiv

ityEm

ployment

Other

(15)

Baleetal.,1980

(Califo

rnia,U

SA)

[40]

Prospective

controlledstu

dydesig

n(astreated

analyses)

Outcomes

aer

1year

585male

veterans

addicted

toheroin

enterin

gwith

draw

alTx

FU:93.2%

Veterans

staying

long

(≥50

days)

(𝑛𝑛𝑛𝑛𝑛)o

rsho

rtin

TCprogram

(<50

days)(𝑛𝑛𝑛𝑛𝑛)

Con

trols:

MMT

(𝑛𝑛𝑛𝑛𝑛);detox

only(𝑛𝑛𝑛𝑛𝑛𝑛);

detox+otherT

x(𝑛𝑛𝑛𝑛𝑛𝑛)

1-year

retention

rate:<

5%in

TCversus

74.5%in

MMT

Recent

heroin

use+

anyillicit

drug

use

lower

inlong

TCsubjects

(37.3and

29.3)than

detox

only-group

(65.5and

46.9)∗∗,but

notthan

MMTgrou

p(46.6and

38.6%)

Arrest(37.3%),

convictio

n(21.3%

)and

reincarc

(4%)

ratesig

nlower

than

indetox

only-group

(54.5∗

∗,38∗

∗

and21.1%∗∗

∗,

resp.),

butn

otthan

MMT

grou

p(49.2,22,

and10.2%)

Employm./schoo

lattend

ance:65.3%

oflong

TCgrou

p,50.9%of

MMTand

38.4%∗∗

∗of

detox

only-group

Sign

.more

subjectshad

good

glob

alou

tcom

escore

inlong

TC(64%

)and

MMT(54.45%)

versus

detox

only-group

(33.8%

)

TCwith

confrontational

styleleast

successfu

lShortT

Cgrou

pdidno

tscore

sign

bette

rthandetox

only-group

Twicethe

number

oflong

TCsubjects

(29.3%

)had

the

max.global

outcom

escore

than

MMTclients

(14%

)

(29)

Coo

mbs,1981

(Califo

rnia,U

SA)

[41]

Prospective

controlledstu

dydesig

n(group

allocatio

nby

self-selection)

Outcomes

11–1

8mon

thsa

er

leavingTC

207heroin

addictsstarting

treatmentinon

eof

2TC

sFU

:78.5%

Long

-term

TC(𝑛𝑛𝑛𝑛𝑛)

12mon

thprogram

Con

trols:

short-term


3mon

thprogram

Program

completion:

63.6versus

74.6%

Total

abstinence:

4.3versus

0%;

Return

toheroin

use:

28.6versus

53%

Program

graduates

used

lesso

enillicitdrugsa

ndwerelesslikely

tohave

relapsed

orto

berearreste

dcomparedwith

splittees.A

lsohigh

erem

ploymentrates

amon

ggraduates

TC:therapeuticcommun

ity,M

TC:m

odi�ed

therapeutic

commun

ity;SR:

self-repo

rted;�

ES:�

uasi-experim

entalstudy

;Tx:

treatment;TIP:

timein

program;B

�I:Be

ck�epressionInventory;

ASI:A

ddictio

nSeverityIndex;levelofsigni�cance:∗P<0.05;∗

∗P<0.01;∗

∗∗P<0.001.

e Scienti�c World �ournal 17

T2:Summaryof

the�

ndings

from

thes

electedstu

dies

(𝑛𝑛𝑛𝑛𝑛).

Referencen

umbero

fthe

study/studies

Type

ofTC

Com

paris

oncond

ition

Follo

wup

leng

thOutcomem

easures

Retention

Substance

use

Crim

inal

activ

ityEm

ployment

Health

Family

and

socialrelatio

ns(1)S

acks

etal.,2012

[19]

Priso

nTA

U1year

+

(2)Z

hang

etal.,2011

[44]

Priso

nTA

U1year

=5years

=(3)M

essin

aetal.,2010

[45]

Priso

nOther

TC1year

+=

==

=(4)W

elsh,2007

[37]

Priso

nTA

U2years

=+

+(5)S

ullivan

etal.,2007

[46]

Priso

nTA

U1year

++

(6)M

orraletal.,2004

[47]

Priso

nTA

U1year

=+

=+

(7)Inciardietal.,2004

[28]

Priso

nTA

U

6mon

ths

++

+1year

++

3years

+=

3years6

mon

ths

++

5years

++

(8)P

rend

ergastetal.,2004

[33]

Priso

nTA

U1year

++

2years

+5years

==

+=

=

(9)G

reenwoo

detal.,2001

[25]

Com

mun

ity-based

Other

TC6mon

ths

=+

++

1year

==

+1year

6mon

ths

=+

+(10)

Nem

esetal.,1999

[42]

Com

mun

ity-based

Other

TC1year

6mon

ths

=+

++

(11)

DeL

eonetal.,2000

[24]

Com

mun

ity-based

TAU

1year

+=

+=

2years

+=

++=

+(12)

Nuttbrock

etal.,1998

[38]

Com

mun

ity-based

TAU

1year

−+

+

(13)

McC

uskere

tal.,1997

[51]

Com

mun

ity-based

Other

TC6mon

ths

==

1year

−=

=+

(14)

Hartm

annetal.,1997

[43]

Priso

nTA

U6mon

ths

=+

(15)

Baleetal.,1984

[39]

Com

mun

ity-based

TAU

1year

−+

++

+

2years

++(illicit)

−(alcoh

ol)

++

(16)

Coo

mbs

etal.,1981

[41]

Com

mun

ity-based

Other

TC1year

=+

TC:

erapeutic

Com

mun

ity,O

ther

TC:O

ther

TCmod

ality,TAU

:TreatmentA

sUsual.

18 e Scienti�c World �ournal

psychological symptoms and relational problems among thehigher intensity treatment group. Some studies have includedmultiple control conditions [29], but usually signi�cantdifferences were only observed when the most intensiveintervention was compared with the least intensive treatmentcondition.

Most controlled studies of TC effectiveness have focusedon TCs in prison settings (𝑛𝑛 𝑛 𝑛) that prepare inmatesfor reintegration in society, while seven studies concernedTCs in the community. Whereas a substantial number ofresidents enter community TCs under legal pressure, TCtreatment in prison can be regarded as a different contextgiven the compulsory custody and conditional release termand privileges. Substance use outcomes in community TCswere signi�cantly better than those among controls in �ve(out of 6) studies, while legal outcomes were found to besuperior in three (out of 4) studies of community TCs. Onthe other hand, only in four (out of 7) studies of prison TCs,the experimental group scored signi�cantly better than thecontrol group, and only one study could demonstrate thisdifference beyond the one-year follow-up assessment [28].Six (out of 9) prison TC studies found signi�cantly betterlegal outcomes among TC participants. ree studies coulddemonstrate these gains aer two years, and two studiesfound these bene�ts maintained up to �ve years aer prisonTC treatment [28, 33].

4. Discussion

4.1. Main Findings. is narrative review was based on16 studies that have evaluated the effectiveness of TCs ascompared with other viable interventions regarding variousindicators related with recovery: substance use, criminalinvolvement, employment, psychological well being, andfamily and social relations. �ased on the study �ndings, wecan conclude that there is some evidence for the effectivenessof therapeutic community treatment. Almost two out ofthree studies have shown signi�cantly better substance useand legal outcomes at the �rst follow-up moment aertreatment among persons who stayed in a TC as comparedwith controls. Five studies found superior employment out-comes among TC participants, while another �ve studiesshowed signi�cantly fewer psychological problems in theexperimental group. Only four studies have reported signif-icantly better differential outcomes in at least three outcomecategories. is does not mean that TC participants do notimprove equally on all life domains, but these outcomes oenremained unreported or the observed progress did not differsigni�cantly from that among the control group. Severalreviews [22, 26, 27, 54] have addressed the question whetherTCs generate better outcomes than other interventions, oenleading to con�icting and not really convincing conclusions.Although several studies included in this paper showedimproved differential outcomes [28, 33, 38, 39, 42, 50], these�ndings were observed among varying populations in diversesettings, and few studies have succeeded to replicate the�ndings from other studies in exactly the same conditions.Moreover, some studies [25, 42, 45] have compared modi�edTCs with standard TCs that were not speci�cally adapted

to address the needs of special target groups. In general,such comparisons of one type of (modi�ed) TC with aless intensive (standard) TC model did not demonstratemuch between group differences, given the strong similaritiesbetween both treatment conditions. Consequently, the mainquestion is not whether one type of TC is better thananother intervention/type of TC, but rather which personsbene�t most from (what type of) TC treatment at what pointin the recovery process [22]. Also, uncontrolled treatmentoutcome studies have repeatedly shown fairly similar effectsof various types of residential treatment [55, 56] and whencompared with outpatient methadone treatment [40, 57, 58],demonstrating that—from a longitudinal perspective—nosingle intervention is superior to another. Not the differen-tial effectiveness of TCs, but rather individuals’ assets andcommunity resources and their personal needs and goals willdetermine whether TC treatment is indicated on the road torecovery.

4.2. Towards a Recovery Perspective on TC Treatment. Whilelooking beyond abstinence and desistance is warrantedfrom a recovery perspective [8], six of the selected con-trolled studies did not report other than substance use andlegal outcomes. Stable recovery in opiate addicts has beenprimarily associated with social participation and havingmeaningful activities and purposes in life, rather than withdrug abstinence or controlled drug use [59]. Focus groupswith drug users regarding their perceived quality of liferevealed few speci�c but mostly generic aspects of �o� likewell being, social inclusion, and human rights [60]. Still, apredominant focus on objective socially desirable outcomemeasures (e.g., work, alcohol and drug use, and recidivism)prevails in addiction research, whilemore subjective outcomeindicators like emotional well being, quality of life, or jobsatisfaction have largely been disregarded [61]. Such a broadperspective is also needed in TC research, as it allows amore accurate evaluation of individuals’ personal growthand well being aer TC treatment. Up to now, recoveryhas primarily been measured based on abstinence rates aerTC treatment, while abstinence is not a synonym of nor aprerequisite for recovery [8]. Total abstinence—as requiredduring and expected aer TC treatment—appears not to beself-evident, not even aer a lengthy treatment episode in aTC and subsequent continuing care. TC participants typicallyimprove on most life domains during the �rst months oftreatment and are usually able to maintain this status untilthey leave treatment [26, 48]. However, once individualsleave the TC, success rates tend to drop quickly, especiallyduring the �rst month(s) aer treatment. A recent review oflongitudinal (mostly uncontrolled) TC studies showed that21% to 100% relapsed into drug use six months to six yearsaer leaving treatment [26]. We found substantial relapserates (25%–70%) 12 to 18 months aer leaving treatment,which indicate that 30% to 75% of the studied TC sampledid not relapse within one year aer TC treatment. Althoughthe de�nition of �relapse� varied largely between studies(e.g., any substance use, illicit drug use, regular use, andlast month use), relapse can be addressed in at least twodifferent ways, depending whether one starts from an acute

e Scienti�c �orld �ournal 19

or a continuing care perspective. e former approach seesrelapse as a failure as treated individuals did not succeed toabstain from drug use aer intensive treatment. e latterperspective acknowledges the chronic relapsing nature ofdrug addiction and assumes that relapse is part and parcelof the recovery process and should rather be considered asa learning moment to keep the precarious balance betweenabstinence and relapse [62]. Factors that may contribute torecovery are longer length of stay in the TC (retention) andparticipation in subsequent aercare, since both variableshave been consistently identi�ed as predictors of improvedsubstance use outcomes [23, 26]. Surprisingly, treatmentcompletion was not found to be a predictor of abstinence,but it was associated with reduced recidivism rates in severalstudies of prison TCs [33, 36].

Treatment in TCs for addictions takes time, usuallyaround 6 to 12 months, which heightens the possibility thatresidents leave prematurely [27]. Retention in (longer term)TCs is typically lower than in shorter term programs [42, 51,55], but in general TC residents who stayed longer in treat-ment had signi�cantly better outcomes than persons whodropped out early. is has led to concerns with enhancingretention through the involvement of the family and socialnetwork and the use of senior staff [63] and with promotinginitial engagement through motivational interviewing, con-tingency management, and induction interventions [64–66].An alternative promising way of looking at retention may beto see it as the sum of treatment episodes in different servicesand the accumulation of associated treatment experiencesinstead of de�ning retention as a single uninterrupted stayin one treatment program [67]. Reentry in the communityappears to be a critical point aer TC treatment, if notprepared adequately (e.g., by providing aercare) or if drugusers go back to their old neighborhoods [68]. Some type ofcontinuing support is warranted aer TC treatment not onlyto prevent relapse, but also to link with employment/trainingand to engage in community-based activities. Moreover,treatment discharge should be dealt with in a �exible andindividualized way, since some persons will need to befurther supported or to reenter the community if they aredoing poorly.

e recovery movement starts from a longitudinal app-roach to addiction and other mental health problems [69],but few controlled studies have assessed TC outcomesbeyond a two-year follow-up period. Available studies sug-gest that—despite a fading effect of TC treatment overtime—recidivism rates continued to be signi�cantly betterthan these of controls in three studies of prison TCs [28,33, 37], while �ndings regarding substance use outcomesindicated fewer between group differences. e three-yearfollow-up outcomes of the Delaware prison study showeda 94% relapse rate among the usual care group (traditionalwork release) compared with a 77% relapse rate in the prisonaercare TC group [29]. ese �gures do not only illustratethe relapsing nature of addiction problems, but also pointat the relatively poor effectiveness of treatment programs.Although robust study designs including substantial follow-up periods that are able to retain most respondents in theanalyses are needed, one may not overestimate the lasting

effects of one single (prolonged) treatment episode. Recoveryis considered to be a lengthy process, and continuing care isneeded to maintain recovery that has been initiated during,for example, TC treatment. Some studies have shown thatthe provision of aercare was as or even more effective thaninitial TC treatment [29, 70], and the combination of TCtreatment and subsequent aercare has generated the bestresults [33, 71].

Finally, the study �ndings show that TC treatment hasgenerated bene�cial outcomes in diverse treatment settingsand may have particularly strong effects among severelyaddicted individuals like incarcerated, homeless, and men-tally ill drug addicts [22, 36, 37, 46]. erefore, treatment inTCs should be considered as a speci�c intervention, reservedfor drug addicts withmultiple and severe problems. Althoughoutpatient methadone maintenance therapy is the main-stream addiction treatment worldwide, therapeutic commu-nities for addictions can be regarded as a valuable alternativefor persons who do not do well in outpatient treatment dueto the lack of structure and supports in the community andthe fact that they live in neighborhoods that are pervasivelyaffected by drug abuse [68]. TCs can be supportive placeswhere clients can learn some of the internal control andrefusal skills conducive to stable recovery. Motivation, socialsupport and coping with stress without using substancesappear to be key factors in successful recovery [72].

4.3. Limitations of the Paper. First, most selected studies werepublished in peer reviewed journals. Although the restrictionof peer-review guarantees some form of quality control,it may have induced a selection bias as the likelihood ofretrieving non-English language articles was limited in thisway. Only results that were reported in the published paperscould be included, while it was oen unclear whether thenonreporting of some speci�c outcomes (e.g., recidivism,alcohol use) meant that this information was not collected,not analyzed, or did not yield signi�cant �ndings. Second,substantial heterogeneity has been observed between theincluded studies, not only regarding program and settingcharacteristics, but also regarding sample characteristics andoutcome measures. Despite the common “community asmethod” principle [18], TCs for addictions consist of vari-ous practices and programs with varying treatment length.Standard and modi�ed TC programs have been evaluated inthis paper, as well as TCs in prison settings and aercareTCs. is heterogeneity should be taken into account wheninterpreting the study outcomes. Although the underlyingelements may be fairly similar across TC programs, thedosage of the program and �delity to the concept mayhave varied considerably [22, 27]. Also, types of controlsvaried across studies from waitlist controls to interventionsthat differed only slightly from the experimental group(e.g., residential/longer versus day/shorter TC programs).Another limitation is the use of varying outcome measuresand instruments across studies, which further hampers thereplication and generalization of the �ndings. ird, thissystematic review was not restricted to randomized trials,although the Cochrane collaboration and other proponents

20 e Scienti�c World Journal

of the evidence-based paradigm regard this type of studydesign as the gold standard for the evaluation of evidenceof effectiveness [73]. Given the difficulties to apply thisdesign to long-term and comprehensive multi-interventionslike TCs and the low number of randomized controlledtrials on the effectiveness of TCs, a comprehensive reviewof randomized and nonrandomized controlled studies wasdeemed to be of surplus value in comparison with availablereviews, still generating an acceptable level of evidence [68].Treatment drop-outs may further compromise the validity ofthe reported results. Several studies only included substanceusers who stayed for a substantial period in the TC or whocompleted treatment but made no intent-to-treat analysis ofeveryone who started TC treatment (cf. Table 1). Finally,this is a narrative review of controlled studies that doesnot allow to weigh the �ndings from different studies or toestimate effect sizes. A meta-analysis was not possible at thispoint, given the substantial heterogeneity between programsand the diverse outcome categories and measures that werereported in the selected studies.

5. Conclusion

erapeutic communities for addictions can be regarded asrecovery-oriented programs that produce change regardingsubstance use, legal, employment, and psychological well-being outcomes among drug addicts with severe and mul-tiple problems. Despite various methodological constraints,TCs appeared to generate signi�cantly better outcomes incomparison with other viable interventions in two out ofthree studies. TC programs have usually been evaluatedfrom an acute care perspective with a primary focus onabstinence and recidivism, while a continuing care approachincludingmultiple andmore subjective outcome indicators isnecessary from a recovery perspective. If residents stay longenough in treatment and participate in subsequent aercare,TCs can play an important role on the way to recovery.Abstinencemay be just one resource to promote employmentor enhance personal well being which can in turn contributeto recovering addicts’ participation in community-basedactivities and their social inclusion.

Acknowledgments

is study was supported by the European MonitoringCentre for Drugs andDrug Addiction (EMCDDA) (Contractcode: CT.11.IBS.057). e authors would like to thank Dr.Teodora Groshkova for her support with this comprehensivereview of the outcome literature on TCs for addictions. eyare further grateful to Ilse Goethals and Mieke Autrique fortheir preparatory work for this literature review.

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