Modified Therapeutic Community for Co-Occurring Disorders: Single Investigator Meta Analysis

ABSTRACT

This paper presents the results of a meta-analysis for a single investigator examining the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring substance use and mental disorders (COD). The flexibility and utility of meta-analytic tools are described, although their application in this context is atypical. The analysis includes 4 comparisons from 3 studies (retrieved N = 569) for various groups of clients with COD (homeless persons, offenders, and outpatients) in substance abuse treatment, comparing clients assigned either to an MTC or a control condition of standard services. An additional study is included in a series of sensitivity tests. The overall findings increase the research base of support for the MTC program for clients with COD, as results of the meta-analysis indicate significant MTC treatment effects for 5 of the 6 outcome domains across the 4 comparisons. Limitations of the approach are discussed. Independent replications, clinical trials, multiple outcome domains, and additional meta-analyses should be emphasized in future research. Given the need for research-based approaches, program and policy planners should consider the MTC when designing programs for co-occurring disorders.

KEYWORDS:

• Co-occurring disorders
• meta-analysis
• modified therapeutic community
• severe mental illness
• substance abuse

Acknowledgments

This paper is dedicated to Dr. Steven M. Banks who was instrumental in its conception and development.

The work reported in this paper was supported by (Study 1) grant 1 UD3 SMTI51558, Modified Therapeutic Community for Homeless MICAs: Phase II Evaluation, from the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS)/Center for Substance Abuse Treatment (CSAT), Cooperative Demonstration Program for Homeless Individuals; (Study 2) grant 2 P50 DA07700.0003, Modified TC for MICA Inmates in Correctional Settings, from the National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA); (Study 3) grant 5 KD1 TI12553, Dual Assessment and Recovery Track (DART) for Co-Occurring Disorders, from the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) GFA TI 00-002 Grants for Evaluation of Outpatient Treatment Models for Persons with Co-Occurring Substance Abuse and Mental Health Disorders (short title Co-Occurring Disorders Study); and (Study 4) grant 1 UD1-SM52403, Integrated Residential/Aftercare TC for HIV/AIDS and Comorbid Disorders, from the Center for Mental Health Services (CMHS) with Health Resources and Services Administration (HRSA) HIV/AIDS Bureau, National Institutes of Health (NIH), National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), GFA No. SM 98.007, FCFDA No. 93.230, Cooperative Agreements for an HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study. Views and opinions are those of the authors and do not necessarily reflect those of the Department of Health and Human Services, SAMHSA, CSAT, or the National Institutes of Health, NIDA.

The authors wish to express their appreciation to Drs. Barry Brown and Frank Pearson for their insightful comments and invaluable assistance in the preparation of the manuscript.

Notes

*P < .05;

***P < .001.

^†An odds ratio less than 1 indicates a greater improvement for clients in the MTC group than in the comparison group.

*P < .05;

**P < .01;

***P < .001.

^a Test 1—The measure showing the largest MTC treatment effect was treated as an outlier and removed in every domain with 2 or more measures (i.e., substance use, mental health, crime).

^b Test 2—A measure with limited treatment effect (i.e., half the strength of the average of the observed measures) was added to each study in every domain.

^c Test 3—A hypothetical study with no treatment effects was added. This study had the average number of subjects (92 MTC and 51 comparison = 143), and the same number of measures for each domain. An odds ratio of 1.00 and the mean standard error from all other studies were assigned to the hypothetical study.

^d Test 4—All HIV cases were included.

^eAn odds ratio less than 1 indicates a greater improvement for clients in the MTC group than in the comparison group.

^f Sensitivity tests were not conducted on the HIV-risk behavior domain because results for original findings were not significant.

1. The modified therapeutic community has traditionally been abbreviated to “modified TC”; however, in this paper, the short form “MTC” has been used throughout, primarily for the reader's convenience and for consistency with individual study usage.

2. In Study 4 (HIV/AIDS), both the experimental and comparison groups received MTC treatment; in other words, the experimental comparison involved residential aftercare for which a non-MTC control group was not available. This study was not included in the meta-analysis; instead, the results of a pre-post test are presented separately.

3. If the odds ratio is written as OR (0.65 in this case), and the relapse rate is written as p (30% or 0.30 in this case), then the relapse rate for the MTC group is determined by: Relapse rate = OR/(((1 − p)/p) + OR).