Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: crime outcomes.
Sacks S., Chaple M., Sacks J.Y. et al. Journal of Substance Abuse Treatment: 2012, 42, p. 247–259.

From the USA, the first randomised trial of a post-prison therapeutic community designed for psychologically disturbed problem substance using offenders found it halved the numbers reimprisoned and did even better when preceded by similar in-prison treatment, confirmation that what happens when people leave prison can be critical.

Summary
Therapeutic communities are residential facilities with a distinctive therapeutic ethos and programme founded on joint living and peer influence. Core principles and methods include: a focus on the 'whole person'; a highly structured daily regimen; fostering personal responsibility and self-help in managing difficulties; using peers as role models and guides, with the peer community acting as the healing agent; regarding change as a gradual, developmental process and moving clients through progressive treatment stages; stressing work and self-reliance through the development of vocational and independent living skills; and promoting prosocial values within healthy social networks to sustain recovery.

Development of therapeutic communities for dual diagnosis prisoners:
Implemented in the community such facilities have reduced drug use and crime while increasing employment rates. Implemented in and adapted to the prison setting, they have led to significantly greater reductions in recidivism to drug use and crime than usual procedures, especially when followed on release by continuing care in a therapeutic community.

Therapeutic communities have also been adapted to the needs of problem substance users who suffer from serious psychiatric symptoms. Programmes are more flexible and less intense, activities are sustained for shorter periods, confrontation is reduced, more guidance and instruction is offered, sanctions are fewer, achievements are more explicitly affirmed, and there is greater sensitivity to individual differences.

These adapted communities have been implemented in prisons for offenders with both substance use and mental health problems. Further modifications have included a cognitive–behavioural curriculum on criminal thinking and behaviour and classes on the relationships between substance use, mental illness, and criminality. These components together with the core elements are expected to curb criminal behaviour more effectively than usual prison regimens.

Colorado communities evaluated:
Such facilities have been introduced in the US state of Colorado, where prisoners assessed as needing prison treatment programmes are required to attend them. The most psychiatrically disturbed are sent to a special facility, but the remaining population with substance use and mental health problems at entry could be required to undergo suitable treatment in prison, for which one option is a modified community of the type described above.

A study set in the same Colorado prisons as the featured study found that these communities did reduce post-release criminal recidivism compared to usual prison mental health and substance use services. Notably, just 9% of offenders randomly allocated to them were re-imprisoned compared to 33% after usual procedures. The figure was even lower among former community residents who on release entered the compatible residential parole programme. Former residents who did not enter the parole programmes evidenced no statistically significant crime reductions compared to usual procedures, though their reimprisonment rate remained less than half that of comparison offenders.

Featured study tests the parole phase:
The post-prison phase was the focus of the featured study. In the previous study continuing care of offenders paroled from prison seemed to reduce crime. However, the offenders had not been randomly allocated to the parole programme, so this apparent effect might have been due to the type of offenders who opted for or were offered a place. Like the original study, the featured study recruited prisoners with both substance use and mental health problems, but instead of randomly allocating them to different prison regimens, it randomly allocated paroled prisoners to the modified community's continuing care programme or to usual facilities.

The specialist community programme was similar to the in-prison regimen – an intensive programme reliant on peer influence and guidance and based on therapeutic community principles adapted for offenders with both substance use and mental health problems. The usual facilities against which this was benchmarked were also residential, but the programme was less intense and consisted mainly of linking parolees to services in the community rather than providing them directly.

To join the study prisoners had to have been treated for their substance use and mental health problems at one of nine Colorado prisons and accepted for residential aftercare on leaving. Of 512 inmates offered the opportunity to participate in the study, 92 refused and 221 were refused a place in a community-based drug treatment facility. After other losses, 127 inmates were randomly assigned to the two parole care regimens. Just over half had at some time been homeless, nearly 80% had been treated for mental health problems, and when recruited to the study on average they were experiencing severe psychological distress. Over 8 in 10 had used cocaine, two thirds amphetamines, and half opiates. All had committed a drug-related offence and most too property and violent offences.

Main issue for the study was the impact of the aftercare regimen, but it also checked whether this worked better if prisoners had already been through the corresponding in-prison programme. Also of interest was whether regardless of the aftercare regimen this prison programme had (as in the previous study) been more effective than usual prison support.