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.
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.
The MTC model is a modification of the conventional therapeutic community approach, altered in ways that make it more suited for offenders presenting with both substance abuse issues and mental illness. The major elements of the MTC program include individual and group counseling, evaluations and monitoring of mental health issues, and medical management of both psychiatric and physical health concerns (Sacks et al., 2004). The MTC model conceptualizes recovery and treatment across four specific phases (e.g., see Sacks, Banks, McKendrick, & Sacks, 2008; Sacks et al., 2004; Sullivan et al., 2007):
(1) Admission to the program. Offenders are oriented regarding what to expect while enrolled in the program.
(2) Primary treatment phase. This phase includes group and individual counseling, medication management, and assistance with issues such as readjustment and community reintegration.
(3) Live-in community reentry. This segment begins during incarceration or in a halfway-house setting upon release.
(4) Live-out community reentry. A transitional stage that allows members to continue treatment while living in the community for a specified period of time.
Live-in aspects of the program are conducted daily from 8:00 AM to 8:00 PM with scheduled breaks. Live-out aspects are designed to accommodate the client's employment schedule while maintaining a regular treatment routine. Programs are typically funded through state appropriations and/or federal grants. In-house programs require medical staffing — including psychiatrists, physicians, and nurses — as well as counselors trained in both psychiatric treatment and substance abuse, and supervisory and security personnel. Live-out programs require each client to be followed by a corrections or probation officer, a physician and/or psychiatrist, and a counselor.
Areas targeted for program assessment include substance use, criminal behavior, psychological problems, employment (during the live-out phase), economic benefit to communities, and housing stability for clients.
Counselors are encouraged to approach both chronic mental disorders and substance dependence as conditions having elements of both shared and individualized manifestation, both of which can fit within a model of recovery and treatment. The counselor's goal is to help stabilize acute symptoms and then assist the individual in accepting and engaging in a long-term program of maintenance, rehabilitation, and recovery. Counselors approach dual diagnosis with the understanding that each diagnosis is considered primary and that either diagnostic problem can exacerbate the symptoms of — and interfere with the treatment of — the other. Individual sessions help to personalize treatment, while group sessions address shared concerns.
The phases of recovery for dual diagnosis patients are understood to follow an established progression: acute stabilization, engagement in treatment, prolonged stabilization and maintenance, and finally rehabilitation and recovery (Minkoff, 1989). Osher and Kofoed (1989), in discussing the treatment of dual diagnoses, expanded the engagement stage to provide counselors a focused framework for working with this population; their substages include engagement, persuasion, active treatment, and prolonged stabilization. The counselor's goal is to help the client reach a period of prolonged stabilization and develop an understanding of both their personal issues and the general characteristics of the conditions they face. Recovery depends substantially on patient motivation, which varies from individual to individual. Counselors therefore work to engage clients in active treatment as a means of enhancing motivation (Minkoff, 1989; Osher & Kofoed, 1989).
"Community resistance, trained staff shortages, advocacy"
"Assessment tools, recidivism tracking, long-term follow-up"
"Practitioner takeaways and future research directions"
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