Therapeutic community is a participative, group-based approach used to treat long-term mental illness, personality disorders and drug addiction. The approach is usually residential, with the clients and therapists living together, but increasingly residential units have been superseded by day units. Therapeutic communities can be based in custodial and non-custodial settings, and aim to induce behavioural change, usually in drug using offenders.
Using a hierarchical set up and communities of professionals and former drug users, these communities use work as an organising therapeutic activity. While many communities request that participants stay for periods of time ranging for 9 to 18 months, drop-out rates are usually high. Therapeutic communities have been used for both adults and juveniles, and aim to promote lasting behavioural change and encourage the development of positive social identities amongst participants.
This narrative is based on one review of 42 studies, which focused on therapeutic communities in custodial settings, and a second review based on 7 studies, 2 of which were in a prison setting. The crime outcome measured in the reviews was reoffending.
Overall, the evidence suggests that therapeutic communities have reduced crime, but there is some evidence from 2 studies that they have increased crime.
The overall evidence comes from Review 1, based on 42 studies. A meta-analysis of outcomes from 35 of the studies, which addressed adults only, showed a statistically significant reduction in reoffending amongst participants who took part in therapeutic communities compared to control groups with no treatment.
When dividing the therapeutic community into different types, and excluding statistical outliers which distorted the results, 15 studies of standard therapeutic communities for adults showed a significant 2% decrease in reoffending in experimental groups compared to control groups. The 8 studies which were referred to as ‘social therapy’ for adults also showed a significant 13% decrease in reoffending amongst those who took part in therapeutic communities compared to control groups. The implementation section below discusses in more detail the differences between types of therapeutic community.
Another meta-analysis of 7 studies using only juveniles saw a decrease in reoffending, but this was not statistically significant. There was also no significant difference between effect sizes for studies of higher and lower quality, or which were published or unpublished. It is important to note that the 2 studies (from Review 1) which showed statistically significant increases in reoffending after taking part in therapeutic communities were both given a quality rating of ‘poor’ by the review authors.
The review was sufficiently systematic that many forms of bias that could influence the study conclusions can be ruled out.
Review 1 considered many elements of validity, conducted relevant statistical analyses and used quality assurance to ensure the accuracy of the information collected from primary studies. It also took into account the potential effects of publication bias, and the possible effect of statistical outliers. However, it did not take into consideration whether different study designs produced different effect sizes, or whether there were any potential unanticipated outcomes.
One potential bias from the studies within the review was their quality – only 3 of the 42 studies had a quality rating of excellent, 7 were rated as good, while 10 were rated as poor and another 22 were rated as fair.
Review 1 noted that therapeutic communities focus upon treating the person, rather than the drug use, and seek to bring about behavioural change and a positive identity in the participant.
The drug abuse is seen as a symptom of immaturity which includes being unable to postpone gratification, tolerate frustration, or maintain healthy, stable relationships. Most drug users are also seen as having conduct or behavioural problems and low self-esteem, which therapeutic communities seek to change.
Positive social values are encouraged within the communities, including honesty, self-reliance, and responsibility to oneself and significant others.
Within therapeutic communities, new participants are encouraged to act ‘as if’ they accept the basic values and rules of conduct and suspend judgement. The resident then continues to act ‘as if’ until these new positive social values are internalised. Participants develop maturity and responsibility through the roles and responsibilities they take on within the communities, and the hierarchical setup of therapeutic communities mean that participants learn to accept authority. The community re-socialises participants from immaturity to adulthood. It uses the community to support the process of self-examination, the development of accountability towards authority, and group interpersonal processes.
Therapeutic communities use groups and meetings to provide 'positive persuasion' to change behaviour, and confrontation by peer groups whenever values or rules are breached. Peers also provide supportive feedback such as reinforcement, affirmation, instruction and suggestions for changing behaviour and attitudes, and assist the residents during group meetings as they recall painful memories from childhood and adolescence.
Review 2 noted that therapeutic communities might assist in preventing crime since many drug users support their drug taking with criminal activity. Participants in therapeutic communities often have multiple drug addictions, mental health problems, inadequate family and social support, and involvement with the criminal justice system. Review 2 echoes Review 1 in noting that peer influence is used to help participants learn social norms and develop effective social skills, and that the community is a key agent of change. This community is made up of staff and other participants receiving treatment, and treatment stages reflect increased levels of personal and social responsibility.
Review 2 states that ‘self-help’ is a fundamental principal of therapeutic communities, with the participants themselves being the main contributor to the process of change.
Review 1 separated the studies into different types of therapeutic community. They found that standard therapeutic communities/milieu therapy for adults and ‘social therapy’ for adults showed significant decreases in reoffending, though the ‘social therapy’ studies showed a slightly larger decrease. The ‘social therapy’ studies were all conducted in Germany.
The review also separated studies involving adults from those for juveniles, finding that while adult participants in therapeutic communities showed a statistically significant decrease in reoffending, the decrease in reoffending seen in juvenile participants was not significant.
Review 2 considered a number of important moderators, including the type of substance misused by participants, the reasons for attendance at therapeutic communities (voluntary or court ordered), the treatment setting (in or out-patient) and the duration of stay in the community. However, the review authors were unable to synthesise information about these within the review.
Review 1 noted that a typical therapeutic community is a community-based residence with a few professional staff, but primarily recovered addicts serving as staff. Residents are asked to spend about 9 to 18 months in residence, but the dropout rate or attrition rate is quite high – usually 60-80% of residents leave within the first three months. When therapeutic communities are conducted within prisons, this dropout rate averages around 50%, compared to 70-90% in non-custodial settings. Therapeutic communities in prison are also much more constrained by rules and policies of the prison setting, including security requirements.
A core characteristic of most therapeutic communities is the use of work as an organising therapeutic activity. This means residents are involved in all aspects of the community’s operations including administration, maintenance and food preparation. Therapeutic communities are hierarchically organised and staff and resident roles are aligned in a clear chain of command. New residents are assigned to work in teams with the lowest status, but can move up as they demonstrate increased competency and emotional growth. Residents have an incentive to earn better work positions, associated rights and privileges, and improved accommodation.
Therapeutic communities increasingly provide additional services such as family treatment and educational, vocational, medical and mental health services, and increasing proportions of professionals from the mental health, medical and education fields are being used.
Milieu therapy is a variant of therapeutic communities, and also involves the use of the community in the behavioural change process. Milieu therapy differs from the therapeutic community in that it is typically more permissive, less structured, democratic rather than hierarchically organised, uses fewer confrontational methods and rather than promoting recovering ex-addicts or ex-offenders employs more professionally trained staff and especially trained custodial officers. Therapeutic communities involve more role-rehearsal, i.e. “acting as if”, and more direct confrontation for rule breaches and failure to progress. Milieu therapy more frequently emphasises the use of traditional group counselling and psychotherapy, i.e. psychodrama, as well as individual psychotherapeutic methods.
Review 1 noted that the process of behavioural change begins within therapeutic communities in prison but must continue in the community if it is to have a genuine and lasting effect, as it takes about two years on average for behavioural changes to be adopted and a positive personal-social identity acquired. When analysing the effect of dosage of treatment in therapeutic communities, the review found that longer programmes had significantly larger decreases in reoffending than shorter programmes. This translated to a 6% differential in recidivism success rates with an increase in time in treatment from 5 to 11 months.
Review 2 noted implementation details of individual studies, all of which occurred in prison. Two of the programmes lasted for 12 months, and one of the programmes described how prisoners attended formal therapeutic community activities five days a week for 4-5 hours a day, with the rest of the time spent on prison work. All of the studies included an invitation to join a therapeutic community once released from prison.
Neither review had any information about costs or benefits.
Overall, the evidence suggests that therapeutic communities have reduced crime, but there is some evidence from 2 studies that they have increased crime. Therapeutic communities are usually populated by drug using offenders, and can operate in custodial settings and within the community. By using hierarchical structures, therapeutic communities encourage participants to respect authority, work towards behavioural change and adopt a positive identity. While significant decreases in reoffending were seen in adult participants compared to control groups, the decreases in juvenile participants were not significant. Drop-out rates are often high, and the evidence suggests that longer programmes see better results than shorter programmes, as behavioural changes takes time to be fully adopted.
Review 1: Lipton, D. S., Pearson, F. S., Cleland, C. M., & Yee, D. (2002) 'The effects of therapeutic communities and milieu therapy on recidivism', In J. McGuire (Ed.), Offender rehabilitation and treatment: Effective programmes and policies to reduce re-offending. Etobicoke: John Wiley Canada. Review 2: Smith, L.A., Gates, S. and Foxcroft, D. (2006) 'Therapeutic communities for substance related disorder', Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005338. DOI: 10.1002/14651858.CD005338.pub2
This narrative was prepared by UCL Jill Dando Institute and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC). ESRC Grant title: 'University Consortium for Evidence-Based Crime Reduction'. Grant Ref: ES/L007223/1.