Correctional Therapeutic Community for Substance Abusers
Correctional Therapeutic Community (CTC) for Substance Abusers is an in-prison residential treatment intervention for incarcerated offenders who have histories of multiple drug-involved arrests and chronic substance abuse, are eligible for the in-prison work release program, and are 6 months from prison release. It is designed to reduce any type of rearrest, increase abstinence from illicit drug use, reduce illicit drug use relapse, and increase postrelease employment among participants. The 6-month intervention is provided as part of a work release program in which participants become residents in an in-prison work release therapeutic community facility separated from the rest of the prison population.
During the first 3 months of CTC for Substance Abusers (i.e., 4-6 months from prison release), residents participate in the first three phases of a five-phase therapeutic community model of treatment for substance abuse:
- Phase 1 of the treatment model consists of assessment, evaluation, and orientation into a CTC. Each new resident is assigned a primary counselor who conducts a needs assessment.
- Phase 2 emphasizes the residents' active involvement in the CTC, including such activities as morning meetings, group therapy, one-on-one interaction, confrontation of other residents who are not motivated toward substance abuse recovery, and nurturing of newer residents. Residents begin to address their own issues related to substance abuse and criminal activity in group sessions and during one-on-one interactions.
- Phase 3 stresses role modeling and overseeing the working of the CTC on a daily basis (with the support and supervision of the clinical staff). So residents develop a strong sense of community, they are organized into a hierarchical structure by roles and job functions, which are associated with strict behavioral expectations and corresponding rewards or sanctions. The rewards or sanctions are applied jointly by staff (many of whom are former offenders or recovering adults who formerly abused substances and act as role models) and residents who act as role models for newer residents.
During the final 3 months of CTC for Substance Abusers (i.e., the 3 months leading up to prison release), residents are permitted to work in the community as part of the work release program while participating in the last two phases of the treatment model:
- In phase 4, residents are prepared for gainful employment and participate in mock interviews; attend seminars on job seeking; and receive information on how to dress, prepare a resume, make the best impression on a potential employer, develop relationships with community agencies, and look for ways to further educational or vocational abilities.
- Phase 5 includes reentry into the community and consists of the residents becoming gainfully employed in the community while continuing to live in the in-prison work release therapeutic community facility and serving as a role model for those in earlier stages of treatment. Also during this phase, residents open a bank account and begin to budget for housing, food, and utilities.
After prison release, participants are encouraged to enter aftercare treatment programming (e.g., outpatient counseling, group therapy) in a therapeutic community environment, under the supervision of parole or other surveillance program.
The primary clinical staff members who deliver CTC for Substance Abusers are typically recovering adults who formerly abused substances and who, ideally, also received treatment in a therapeutic community. These staff members are complemented by counselors who have received formal education. All implementing staff must receive intervention-specific training. In addition, implementation requires mutual cooperation, support, and ongoing communication between intervention staff, correctional security personnel, and the prison warden.
Descriptive Information
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Areas of Interest
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Mental health promotion
Substance use disorder treatment
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Outcomes
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1: Rearrests
2: Abstinence from illicit drug use
3: Illicit drug use relapse
4: Employment
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Outcome Categories
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Crime/delinquency
Drugs
Employment
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Ages
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26-55 (Adult)
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Genders
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Male
Female
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Races/Ethnicities
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Black or African American
Race/ethnicity unspecified
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Settings
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Residential
Correctional
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Geographic Locations
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Urban
Suburban
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Implementation History
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CTC for Substance Abusers was first implemented at the New Castle County Work Release Center. The intervention had been implemented in Delaware's other two work release centers, in Kent and Sussex Counties. According to the National Institute of Justice national evaluation of the Residential Substance Abuse Treatment for State Prisoners program, more than 50,000 criminal justice clients participated in CTC for Substance Abusers during the period of evaluation. Interested implementers from more than 30 countries have visited the Delaware-based implementation, and the intervention model has been used in Argentina, Australia, Austria, Belgium, Bulgaria, Panama, the Philippines, Romania, Spain, and Thailand. The Delaware-based intervention was evaluated for process and outcome findings (including a 15-year follow-up study), resulting in more than 200 papers, books, and presentations. Two other implementations in the United States (in California and Texas) and one in Australia also have been evaluated.
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NIH Funding/CER Studies
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Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
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Adaptations
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CTC for Substance Abusers has been modified to be implemented as a 12- to 18-month residential treatment program for individuals with co-occurring substance use and mental disorders. This program, Modified Therapeutic Community (MTC) for Persons With Co-Occurring Disorders, has been reviewed separately by NREPP.
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Adverse Effects
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No adverse effects, concerns, or unintended consequences were identified by the developer.
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IOM Prevention Categories
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Selective
Indicated
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Quality of Research
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Butzin, C. A., Martin, S. S., & Inciardi, J. A. Treatment during transition from prison to community and subsequent illicit drug use. Journal of Substance Abuse Treatment, 28(4), 351-358.
Inciardi, J. A., Martin, S. S., & Butzin, C. A.. Five-year outcomes of therapeutic community treatment of drug-involved offenders after release from prison. Crime and Delinquency, 50(1), 88-107.
Martin, S. S., O'Connell, D. J., Paternoster, R., & Bachman, R. D. The long and winding road to desistance from crime for drug-involved offenders: The long-term influences of TC treatment or re-arrest. Journal of Drug Issues, 41(2), 179-196.
Supplementary Materials Criminal Justice Committee of Therapeutic Communities of America. Therapeutic communities in correctional settings: The Prison Based TC Standards Development project. Final report of phase II. Washington, DC: Executive Office of the President, Office of National Drug Control Policy.
Inciardi, J. A. Final report: Grant no. 5R37 DA6124-15. Ongoing studies of treatment for high risk drug abusers.
Inciardi, J. A., & Lockwood, D. When worlds collide: Establishing CREST Outreach Center. In B. W. Fletcher, J. A. Inciardi, & A. M. Horton (Eds.), Drug abuse treatment: The implementation of innovative approaches (pp. 63-78). Westport, CT: Greenwood Press.
Lockwood, D., Inciardi, J. A., & Surratt, H. L. CREST Outreach Center: A model for blending treatment and corrections. In F. M. Tims, J. A. Inciardi, B. W. Fletcher, & A. M. Horton Jr. (Eds.), The effectiveness of innovative approaches in the treatment of drug abuse (pp. 70-82). Westport, CT: Greenwood Press.
Martin, S. S., Butzin, C. A., Saum, C. A., & Inciardi, J. A. Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: From prison to work release to aftercare. Prison Journal, 79(3), 294-320.
Outcomes
| Outcome 1: Rearrests |
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Description of Measures
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Rearrests were measured by participants' self-report of rearrests and by official arrest records. At each follow-up assessment, participants responded "yes" or "no" to a question asking whether they had been rearrested. Each participant's self-report was cross-checked against arrest records from the Delaware Statistical Analysis Center (SAC) and the Interstate Compact Offender Tracking System (ICOTS), which can be used to track arrests in other States and territories. If a participant reported no rearrests, but the SAC or ICOTS had a record of a rearrest, then the measure was coded as a rearrest. If a respondent reported a rearrest, but there was no official rearrest record in the SAC or ICOTS, the measure was still coded as a rearrest.
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Key Findings
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In a quasi-experimental field trial, incarcerated offenders who had drug-involved arrests and a history of chronic substance abuse and who were eligible for a work release program (as determined by criminal history and correctional counselor interviews) during the 6 months before prison release were assigned to the intervention or control group. Participants in the intervention group received CTC for Substance Abusers, and those in the control group participated in the standard work release program for the full 6 months before prison release (i.e., working or going to school in the community on weekdays and returning to the in-prison dormitory at night and on weekends). Some participants in the intervention group also received treatment in a prior, in-prison therapeutic community and/or received aftercare treatment programming in a therapeutic community environment following prison release. Assessments occurred at prison release, which coincided with the completion of the 6-month intervention or the standard work release program (i.e., 6 months after study entry), and at 1-, 3-, and 4.5-year follow-ups (i.e., 18, 42, and 60 months after study entry, respectively). Findings included the following:
- From prison release to the 3-year follow-up, participants in the intervention group were less likely than those in the control group to be rearrested (p = .003). This group difference was associated with a small effect size (odds ratio = 1.71).
- From prison release to the 4.5-year follow-up, participants in the intervention group were less likely than those in the control group to be rearrested (p = .017). This group difference was associated with a small effect size (odds ratio = 1.61).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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2.4
(0.0-4.0 scale)
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| Outcome 2: Abstinence from illicit drug use |
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Description of Measures
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Abstinence from illicit drug use was assessed through the following:
- Self-report of drug use. Participants were asked whether they had used any illicit drugs since the previous assessment, and if so, they were asked to recall when that illicit drug use had first occurred and to report the frequency of that use on a scale ranging from 0 (no use) to 6 (used more than once a day).
- Self-report of living situation and associated drug use. Participants were asked to recall where they were living at the time of the previous assessment and to report the frequency of illicit drug use while living there on a scale ranging from 0 (no use) to 6 (used more than once a day). The process was repeated for the next residence until the complete period between follow-up assessments was described by type of residence and frequency of any associated illicit drug use.
- Urinalysis. Participants were asked to provide a urine sample at each follow-up assessment. The urine sample was tested for the presence of opiates, marijuana, cocaine, barbiturates, phencyclidine, and amphetamines.
If none of the measures indicated illicit drug use, the participant was classified as being abstinent through the last available assessment date.
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Key Findings
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In a quasi-experimental field trial, incarcerated offenders who had drug-involved arrests and a history of chronic substance abuse and who were eligible for a work release program (as determined by criminal history and correctional counselor interviews) during the 6 months before prison release were assigned to the intervention or control group. Participants in the intervention group received CTC for Substance Abusers, and those in the control group participated in the standard work release program for the full 6 months before prison release (i.e., working or going to school in the community on weekdays and returning to the in-prison dormitory at night and on weekends). Some participants in the intervention group also received treatment in a prior, in-prison therapeutic community and/or received aftercare treatment programming in a therapeutic community environment following prison release. Assessments occurred at study entry; at prison release, which coincided with the completion of the 6-month intervention or the standard work release program (i.e., 6 months after study entry); and at 1-, 3-, and 4.5-year follow-ups (i.e., 18, 42, and 60 months after study entry, respectively). Findings included the following:
- From prison release to the 3-year follow-up, participants in the intervention group were more than 4 times as likely as those in the control group to be abstinent from illicit drug use (p < .001). This group difference was associated with a medium effect size (odds ratio = 4.49).
- From prison release to the 4.5-year follow-up, participants in the intervention group were more than 3.5 times as likely as those in the control group to be abstinent from illicit drug use (p < .001). This group difference was associated with a medium effect size (odds ratio = 3.54).
- Also from prison release to the 4.5-year follow-up, participants in the intervention group had a larger proportion of time abstinent from illicit drug use than those in the control group (p < .0001). This group difference was concentrated in the first 3 years following prison release; that is, participants in the intervention group had a larger proportion of time abstinent from illicit drug use than those in the control group from prison release to the 1-year follow-up (p < .001) and from the 1- to 3-year follow-up (p < .001). From the 3- to 4.5-year follow-up, the difference in proportion of time abstinent from illicit drug use was not significantly different between groups.
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Studies Measuring Outcome
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Study 1
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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2.3
(0.0-4.0 scale)
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| Outcome 3: Illicit drug use relapse |
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Description of Measures
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Illicit drug use relapse was assessed through the following:
- Self-report of drug use. Participants were asked whether they had used any illicit drugs since the previous assessment, and if so, they were asked to recall when that illicit drug use had first occurred and to report the frequency of that use on a scale ranging from 0 (no use) to 6 (used more than once a day).
- Self-report of living situation and associated drug use. Participants were asked to recall where they were living at the time of the previous assessment and to report the frequency of illicit drug use while living there on a scale ranging from 0 (no use) to 6 (used more than once a day). The process was repeated for the next residence until the complete period between follow-up assessments was described by type of residence and frequency of any associated illicit drug use.
- Urinalysis. Participants were asked to provide a urine sample at each follow-up assessment. The urine sample was tested for the presence of opiates, marijuana, cocaine, barbiturates, phencyclidine, and amphetamines.
If any of the measures indicated illicit drug use, the time to initial illicit drug use relapse was determined by the first occurring indicator of drug use. If illicit drug use was reported as first occurring during the residential period, the initial date of that period was used as the time to illicit drug use relapse.
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Key Findings
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In a quasi-experimental field trial, incarcerated offenders who had drug-involved arrests and a history of chronic substance abuse and who were eligible for a work release program (as determined by criminal history and correctional counselor interviews) during the 6 months before prison release were assigned to the intervention or control group. Participants in the intervention group received CTC for Substance Abusers, and those in the control group participated in the standard work release program for the full 6 months before prison release (i.e., working or going to school in the community on weekdays and returning to the in-prison dormitory at night and on weekends). Some participants in the intervention group also received treatment in a prior, in-prison therapeutic community and/or received aftercare treatment programming in a therapeutic community environment following prison release. Assessments occurred at study entry; at prison release, which coincided with the completion of the 6-month intervention or the standard work release program (i.e., 6 months after study entry); and at 1-, 3-, and 4.5-year follow-ups (i.e., 18, 42, and 60 months after study entry, respectively). From prison release through the 4.5-year follow-up, the time to illicit drug use relapse was longer for participants in the intervention group than for those in the control group (28.8 vs. 13.2 months; p < .001).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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2.6
(0.0-4.0 scale)
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| Outcome 4: Employment |
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Description of Measures
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Employment was measured by self-report. Participants were asked whether they were employed at least 30 hours each week since prison release.
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Key Findings
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In a quasi-experimental field trial, incarcerated offenders who had drug-involved arrests and a history of chronic substance abuse and who were eligible for a work release program (as determined by criminal history and correctional counselor interviews) during the 6 months before prison release were assigned to the intervention or control group. Participants in the intervention group received CTC for Substance Abusers, and those in the control group participated in the standard work release program for the full 6 months before prison release (i.e., working or going to school in the community on weekdays and returning to the in-prison dormitory at night and on weekends). Some participants in the intervention group also received treatment in a prior, in-prison therapeutic community and/or received aftercare treatment programming in a therapeutic community environment following prison release. Assessments occurred at prison release, which coincided with the completion of the 6-month intervention or the standard work release program (i.e., 6 months after study entry), and at 1-, 3-, and 4.5-year follow-ups (i.e., 18, 42, and 60 months after study entry, respectively). During the follow-up period, the percentage of participants who obtained employment since prison release was higher for the intervention group than the control group (54.6% vs. 45.4%; p < .01).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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1.7
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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26-55 (Adult)
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79.9% Male
20.1% Female
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73.1% Black or African American
26.9% Race/ethnicity unspecified
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Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Rearrests
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3.0
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3.0
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2.8
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0.5
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1.8
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3.4
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2.4
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2: Abstinence from illicit drug use
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3.1
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2.5
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2.8
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0.5
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1.8
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3.4
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2.3
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3: Illicit drug use relapse
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3.1
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2.5
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2.8
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1.9
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1.8
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3.5
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2.6
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4: Employment
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0.0
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0.0
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2.8
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1.9
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1.8
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3.5
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1.7
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Study Strengths Self-reported rearrests were cross-checked against State and interstate arrest databases, staff who retrieved database records were blind to study condition assignments, and mismatches between self-reported rearrests and database records were coded conservatively as rearrests, increasing both the reliability and validity of the outcome measure. The self-reported illicit drug use items came from known interview instruments, and self-reported illicit drug use was confirmed by urinalysis at each assessment point, increasing the validity of the outcome measure in the study population. Staff were trained to deliver the intervention using a written protocol for treatment delivery, and the structured nature of correctional facilities adds to the strength of intervention fidelity. The study design benefited from a long, longitudinal follow-up period after prison release, and covariate predictors were tested to rule out some of the potential confounding variables. Statistic modeling of the data was appropriate and included sophisticated analyses such as survival analyses for two of the four outcomes to address successive waves of participants entering into a longitudinal field study and right censoring of the data (i.e., withdrawal of participants before the outcome is observed).
Study Weaknesses There is no documentation of reliability or validity for the self-report employment measure, and there was no attempt to corroborate self-reported employment with an objective, independent measure of employment, such as a reference check. There was no information on the percentages of intervention group sessions and residential meetings that were rated for fidelity. Missing data were substantial (up to 31%) across the study's follow-up period, and investigators did not model the missing data or compare remaining participants and those lost to attrition on measures at study entry, despite the strong likelihood that the data were not missing at random. Across the follow-up period, there was a moderate amount of missing data handled simply by casewise deletion, despite the possibility that these data were not missing at random. Potential confounds, which make clear interpretations of the outcomes difficult, include the following: nonrandom assignment; lack of an attention control to account for nonspecific treatment elements, such as participant expectations, social desirability, and secondary gain; 3-month differential in access to the outside community between the two study conditions; and the fact that some of the offenders in the intervention group participated in a prior, in-prison therapeutic community and/or participated in an aftercare therapeutic community following prison release.
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Readiness for Dissemination
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Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
American Correctional Association. Performance-based standards for therapeutic communities. Lanham, MD: Author.
The Change Companies. Introduction to therapeutic community. Carson City, NV: Author.
The Therapeutic Community Training Series: Encounter Groups for Addictions, With Rod Mullen [3-video set]:
- Volume I: Evolution of the Encounter Group
- Volume II: Pitfalls and Solutions
- Volume III: Keys to Fostering Growth
The Therapeutic Community Training Series: The Therapeutic Community, With George DeLeon, PhD [3-video set]:
- Volume I: The Therapeutic Community Perspective
- Volume II: Community as Method
- Volume III: Components of a Generic Therapeutic Community
The Therapeutic Community Training Series: Therapeutic Communities in Prison: A Research Perspective, With Harry Wexler, PhD [Video]
Wexler, H. Therapeutic communities within prisons. In G. DeLeon & J. T. Ziegenfuss (Eds.), Therapeutic communities for addictions: Readings in theory, research and practice (pp. 227-237). Springfield, IL: Charles C. Thomas Publisher.
Other program materials:
- Correctional Therapeutic Community (CTC) Training: Overview for Those Adopting the Program.
- Intervention Summary Document
- Roadmap to Dissemination Materials
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
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Training and Support
Resources
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Quality Assurance
Procedures
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Overall
Rating
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3.8
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4.0
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3.0
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3.6
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Dissemination Strengths The required implementation and training materials are easily accessed online and are thorough, easy to read, and easy to understand. The developer provides a list of optional resources that enhance program implementation, including several video sets and high-quality journals. Implementation consultation and ongoing telephone support are available. The developer also provides refresher training upon request. The Performance-Based Standards for Therapeutic Communities book systematically assists implementers in understanding what is needed to obtain accreditation with the American Correctional Association. An outcomes measures worksheet is provided to help the development of quality assurance procedures. Consultation is available to answer questions related to program principles and program evaluation.
Dissemination Weaknesses No matrix, comprehensive outline, or other overview document is provided to strengthen the presentation of materials and allow implementers to easily understand how the program materials work together and in what sequence they should be used. Although the quality assurance materials provide specific elements that can be used to monitor fidelity to underlying therapeutic concepts and principles, there is no fidelity tool that is specific to this program. Some of the quality assurance resources are old copies of documents and are difficult to read.
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Costs
The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements.
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Item Description
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Cost
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Required by Developer
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Therapeutic Community Curriculum: Participant's Manual
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Free
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Yes
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Introduction to Therapeutic Community
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$2.50 each
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Yes
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Key, Crest, Aftercare: Program Manual
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$5 each
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Yes
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Correctional Therapeutic Community (CTC) Training: Overview for Those Adopting the Program
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Free
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Yes
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Residential Drug Abuse Treatment Program Journals (set of 7)
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$34 per set
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No
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Extensions Curriculum for Therapeutic Communities and Demonstrator Guides (8 topical volumes)
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Varies by volume
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No
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Therapeutic Community Curriculum: Trainer's Manual
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Free
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Yes
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Facilitator's Guide for Interactive Journals for Participants in Residential TC Programs for Incarcerated Adults
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Free
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No
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Encounter Groups for Addictions (3-video set)
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$299 per set
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No
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The Therapeutic Community (3-video set)
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$299 per set
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No
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Therapeutic Communities in Prison: A Research Perspective (video)
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$99 each
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No
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Treating Chemically Dependent Criminal Offenders in Corrections (PowerPoint slides)
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Free online, $5 for black-and-white hard copy, or $25 for color hard copy
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Yes
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Onsite training and implementation consultation for new and experienced implementers
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$1,000 per day plus travel expenses
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No
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Therapeutic Communities Within Prisons
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Free
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No
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Performance-Based Standards for Therapeutic Communities
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$28 each
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Yes
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Therapeutic Communities in Correctional Settings: The Prison Based TC Standards Development Project
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Free
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No
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A Statewide Integrated Quality Assurance Model for Correctional-Based Therapeutic Community Programs
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Free
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No
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Additional Information If an implementer requests multiple days of onsite training and/or implementation consultation, a reduced daily rate can be negotiated.
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