Modified Therapeutic Communities for Dual Diagnosis Offenders
This paper examines the population needs of individuals with dual diagnoses — co-occurring mental illness and substance use disorders — and the application of Modified Therapeutic Communities (MTCs) as a treatment model within correctional settings. It begins by clarifying the terminology of "dual diagnosis" and "comorbidity," noting limitations of current diagnostic systems. The paper then outlines the four-phase MTC program structure, counselor roles, assessment strategies, and evaluation methods. Special attention is given to the challenges of implementing live-out community reentry phases, training adequate counseling staff, and measuring long-term outcomes such as recidivism, psychological symptoms, and employment status.
- Introduction: Dual Diagnosis and Comorbidity: Defines dual diagnosis, comorbidity, and diagnostic limitations
- Program Design and Interventions: Four-phase MTC structure, staffing, and funding
- Counselor Involvement and Recovery Phases: Counselor roles and recovery stage framework
- Special Issues in Implementation: Community resistance, trained staff shortages, advocacy
- Evaluation Methods and Outcome Variables: Assessment tools, recidivism tracking, long-term follow-up
- Implications for Counselors: Practitioner takeaways and future research directions
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What makes this paper effective
- It grounds the discussion in a careful definitional analysis of "dual diagnosis" versus "comorbidity," acknowledging scholarly debate before moving to program description — this prevents the reader from uncritically accepting contested terminology.
- The four-phase MTC model is presented with clear structural logic, moving from intake through live-out reentry, making the program design easy to follow and evaluate.
- The paper balances practical program detail (staffing, scheduling, funding) with scholarly citations, demonstrating academic rigor alongside applied focus.
Key academic technique demonstrated
The paper demonstrates effective critical contextualization: before describing the MTC intervention, it situates the target population within a broader debate about diagnostic validity (citing Lilienfeld et al., 1994, and Maj, 2005). This technique shows the reader why the population is difficult to define and treat, making the case for a specialized program more persuasive.
Structure breakdown
The paper follows a logical applied-research structure: (1) population definition and rationale; (2) program description with phases and staffing; (3) counselor roles and therapeutic approach; (4) implementation challenges; (5) evaluation design and outcome variables; and (6) implications for practitioners. Each section builds on the previous, moving from "who needs this" to "how it works" to "how we know if it worked."
Introduction: Dual Diagnosis and Comorbidity
The term dual diagnosis is typically reserved for someone suffering from a mental disorder and a comorbid substance abuse problem, although technically the term comorbidity is more appropriate. There has been some debate in the literature surrounding the use of a single diagnostic label for a group of individuals who present a wide variety of different psychiatric diagnoses and different substance abuse issues (Evans & Sullivan, 2001). The term "comorbidity" was introduced in the medical field in the 1970s by an epidemiologist to describe the presence of more than one distinct disease occurring in an individual at the same time (Feinstein, 1970). The designation of comorbid diseases assisted physicians in prioritizing the treatment needs of these individuals and in understanding how the presence of one disease could increase vulnerability to other conditions.
The terms dual diagnosis and comorbidity are widely used in the field of mental health, as those diagnosed with psychiatric disorders often present with many diverse symptoms. Symptoms such as anxiety, depression, and substance abuse are common manifestations of nearly all mental disorders and have been observed to co-occur with many other psychological problems. The diagnosis of physical diseases occurs on the basis of objective medical test results, whereas the diagnosis of psychiatric disorders is based on subjective feelings, behavioral observations, and some degree of conjecture. The term comorbidity was originally designed to denote the presence of separate but distinct identifiable disease conditions; a dual diagnosis implies a distinct group of such individuals in terms of the way it is phrased (Maj, 2005). In reality, the use of the terms comorbidity or dual diagnosis for mental disorders may not reflect the presence of multiple distinct disorders, but may instead reflect the inadequacy of the DSM and the inability of the mental health field to apply a single diagnostic label for a psychiatric disorder comprised of many different symptoms (e.g., see Lilienfeld, Waldman, & Israel, 1994; Maj, 2005). Moreover, the diagnosis of several comorbid mental disorders in a single individual often reflects a "symptom management" approach to diagnosis in clinical psychiatry and psychology, as opposed to an effort to understand the overall clinical picture (Lilienfeld et al., 1994).
Despite the issues with terms such as "dual diagnosis" and "comorbidity," it has become clear that individuals with mental disorders and co-occurring substance abuse issues present special challenges. People given co-occurring diagnoses face a host of multifaceted challenges in treatment and in other areas of their lives, including increased rates of relapse, re-hospitalization, homelessness, legal difficulties, and substance abuse-related conditions such as Hepatitis C or HIV infection (Center for Co-Occurring Disorders, 2006).
Those individuals with legal issues and dual diagnoses often require special services and monitoring programs to help prevent them from becoming habitual offenders as a result of untreated mental health issues. Correctional institutions are challenged to reduce recidivism in this group. Nationwide, the correctional system has turned to therapeutic community programs to treat offenders who have co-occurring mental and substance use disorders, a group with a mounting prevalence in prison populations (Sullivan et al., 2007). Modified Therapeutic Communities (MTCs) are specially designed for the treatment of offenders who have both mental illness and substance abuse disorders. These programs adapt the therapeutic community model for substance users and apply it to legal offenders — both men and women of all ages — who present with co-occurring disorders (Sacks et al., 2004). Data is collected through record reviews, diagnostic information obtained from legal records and from treating physicians, and clinical interviews with clients suited for the program. The MTC model is especially well-suited to treating this population.
References
Beck, A. T., Brown, G., & Steer, R. A. (1996). Beck Depression Inventory II manual. San Antonio, TX: The Psychological Corporation.
Center for Co-Occurring Disorders. (2006). Overarching principles to address the needs of persons with co-occurring disorders. Retrieved July 25, 2013, from http://store.samhsa.gov/shin/content/PHD1132/PHD1132.pdf
Evans, K., & Sullivan, M. J. (2001). Dual diagnosis: Counseling the mentally ill substance abuser (2nd ed.). New York: Guilford Press.
Feinstein, A. R. (1970). The pre-therapeutic classification of co-morbidity in chronic disease. Journal of Chronic Disease, 23, 455–468.
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Maj, M. (2005). 'Psychiatric comorbidity': An artifact of current diagnostic systems? The British Journal of Psychiatry, 186(3), 182–184.
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Sacks, S., Banks, S., McKendrick, K., & Sacks, J. Y. (2008). Modified therapeutic community for co-occurring disorders: A summary of four studies. Journal of Substance Abuse Treatment, 34(1), 112–122.
Sacks, S., Sacks, J. Y., McKendrick, K., Banks, S., & Stommel, J. (2004). Modified TC for MICA offenders: Crime outcomes. Behavioral Sciences & the Law, 22(4), 477–501.
Sullivan, C. J., McKendrick, K., Sacks, S., & Banks, S. (2007). Modified therapeutic community treatment for offenders with MICA disorders: Substance use outcomes. The American Journal of Drug and Alcohol Abuse, 33(6), 823–832.
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