A systematic review of studies examining effectiveness of therapeutic communities

Abstract

Purpose – The purpose of this paper is to systematically review quantitative research since 2000 on the effectiveness of residential therapeutic communities (TCs) for the treatment of substance-use disorders with reference to substance-use, crime, mental health and social engagement outcomes. Design/methodology/approach – A systematic search with broad inclusion criteria resulted in the review of 11 studies. The studies investigated community-based TCs, as well as TCs modified for prisoners, prisoners transitioning to community living and TCs for individuals with co-occurring substance-use and mental health issues. Findings – Results were analysed by comparing the findings of the studies under investigation, of which three studies investigated within-subjects outcomes, four compared TC treatment with a no-treatment control condition and four compared TC treatment with another treatment condition. Conclusion: consistent with previous systematic reviews of TCs, outcomes varied across studies but indicated TCs are generally effective as a treatment intervention, with reductions in substance-use and criminal activity, and increased improvement in mental health and social engagement evident in a number of studies reviewed. Research limitations/implications – Variability in outcomes suggests further TC research and research syntheses focusing on a second key research question in the evaluation of complex interventions – how the intervention works – could play an important role in understanding TC effectiveness, and for whom it is effective and in what contexts. Practical implications – Although there is some variability in treatment populations included in this review, evidence reported in other studies suggests individuals with severe substance-use disorders, mental health issues, forensic involvement and trauma histories, will benefit from TC treatment. This is supported by the literature which has found a general relationship between severity of substance use and treatment intensity (Darke et al., 2012; De Leon et al., 2008) with outcomes further enhanced by self-selection into treatment and appropriate client-treatment matching (see De Leon, 2010; De Leon et al., 2000, 2008). The weight of evidence gleaned from multiple sources of research, including randomised control trials and field outcome studies (De Leon, 2010) suggests TCs are an important and effective treatment for clients in improving at least some aspects of their quality of life, specifically mental health and social engagement, and in reducing harmful behaviours, including substance-use and crime. Variability in treatment setting and populations reflect the real-world setting in which TC treatment is delivered, providing a multifaceted treatment modality to a complex population in variable circumstances. Originality/value – The strength of the current study is that it provided a broad evaluation of TC effectiveness across a range of outcomes (substance-use, criminal activity, mental health and social engagement), and is therefore valuable in updating the current literature and providing context for future research in this area. It aimed to address a key question in evaluating complex interventions: whether they are effective as they are delivered. Findings suggest that TC treatment is generally effective for the populations of concern in reducing substance use and criminal activity and contributing to some improvement in mental health and social engagement outcomes.

Outcomes of therapeutic community treatment for personality disorder

“…Outcomes in TC research, and for psychotherapy treatment of PD more generally have included a mixture of mental health (clinician, self-report), general distress, behavioural, service use and global outcome measures (Bateman & Fonagy, 2000;Bateman & Tyrer, 2004;Gendreau, Little & Goggin, 1996;Madan & Fowler, 2015;Magor-Blatch et al, 2014). Others have highlighted the significance of identifying interpersonal change post DTC treatment (Heede et al, 2009;Hopwood et al, 2013;Shuker & Newberry, 2010), in line with a TC's main emphasis on providing a corrective emotional experience for individuals to facilitate development of adaptive ways of relating with others.…”

“…More recent attempts have been made to systematically review TC research conducted beyond this time period (Veale et al, 2014;Magor-Blatch et al, 2014). However, these reviews have succumbed to similar issues regarding sample heterogeneity, or failed to distinguish between concept TCs and DTCs, limiting the application of findings.…”

“…[CASP], University of Oxford, 2005; Newcastle-Ottawa Scale, Wells et al, 2010) in addition to methodological issues highlighted by previous reviews specific to therapeutic community research (Magor-Blatch et al, 2014;Lees et al, 2004) were integrated to develop a quality assessment tool for this review.…”

“…Future research should consider adopting a focus on processes inherent within TCs to develop an evidence-based understanding of its most effective components so we might enhance these aspects (Aslan & Yates, 2015;Magor et al, 2014;Veale et al, 2014). As highlighted by Aslan & Yates (2015), in light of the continuous modification of TCs and ongoing therapeutic integration of different theoretical approaches, gaining a deeper understanding of how TCs work would also enable future clinicians to approach TC modification with an understanding that would guard against undermining the core integrity of the model.…”

“…These outcomes were explored in a recent systematic review of TCs (Magor-Blatch et al, 2014) It was beyond the scope of the review to examine other outcome measures of cost effectiveness such as utilization of psychiatric services. Therefore, studies that This is the final version submitted for publication in Therapeutic Communities prior to the publisher's edits (1 st March 2016) focused exclusively on cost efficacy outcomes of democratic TCs were excluded.…”