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Therapeutic communities (during incarceration) for individuals with co-occurring disorders

Adult Criminal Justice
Benefit-cost methods last updated December 2024.  Literature review updated March 2024.
Prison-based therapeutic communities (TC) for co-occurring disorders are an intensive form of treatment provided to incarcerated individuals with both mental health and substance use disorders. Participants remain within correctional facilities and live in a therapeutic residential unit apart from the general prison population. TCs use a hierarchical social learning model, wherein participants earn increased social and personal responsibility as they progress through stages of treatment. Treatment involves a highly structured therapeutic environment, peer support, and peer accountability intended to teach participants prosocial norms and behaviors. Components specific to co-occurring disorders may include psychoeducational classes, cognitive-behavioral protocols, medication, or other therapeutic interventions.

Individuals identified as having co-occurring disorders at prison intake may be assigned to or required to participate in a therapeutic community and may undergo treatment in this setting for a few months to over a year or until release from incarceration, depending on individual needs. TC residents typically receive daily therapeutic programming—both individual and group based—from professional staff in addition to participating in vocational training or correctional industries employment.

This analysis reports outcomes from a single evaluation of an in-prison TC using the Personal Reflections curriculum, in which 57% of individuals assigned to the TC also participated in a residential aftercare program. Outpatient aftercare was available for other TC participants and the comparison group, who received non-TC mental health and SUD treatment while incarcerated. Reported effect sizes represent the cumulative effect of TCs during incarceration followed by aftercare.
 
ALL
BENEFIT-COST
META-ANALYSIS
CITATIONS
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2023).  The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $22,855 Benefits minus costs $73,290
Participants $2,316 Benefit to cost ratio $27.03
Others $41,161 Chance the program will produce
Indirect $9,774 benefits greater than the costs 98%
Total benefits $76,106
Net program cost ($2,816)
Benefits minus cost $73,290

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the program impacts measured in the research literature (for example, impacts on crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information on how we estimate effect sizes.

The effect size may be adjusted from the unadjusted effect size estimated in the meta-analysis. Historically, WSIPP adjusted effect sizes to some programs based on the methodological characteristics of the study. For programs reviewed in 2024 or later, we do not make additional adjustments, and we use the unadjusted effect size whenever we run a benefit-cost analysis.

Research shows the magnitude of effects may change over time. For those effect sizes, we estimate outcome-based adjustments, which we apply between the first time ES is estimated and the second time ES is estimated. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Crime
Involvement in the criminal justice system (e.g., arrests, charges, convictions, incarceration) measured through administrative records (e.g. court records, arrests) or self-report.
 36 1 75 -0.812 0.273 37 -0.812 0.273 45 -0.812 0.003
Substance use disorder
A non-specified alcohol or drug use disorder. Typically, a collection of different types of disorders reported by study authors. 
 36 1 75 -0.490 0.230 37 -0.067 0.345 39 -0.490 0.033
Anxiety disorder
Clinical diagnosis of an anxiety disorder (e.g., general anxiety, panic, social anxiety, obsessive compulsive disorder) or symptoms measured on a validated scale.
 36 1 75 -0.104 0.170 37 -0.054 0.209 39 -0.104 0.541
Major depressive disorder
Clinical diagnosis of major depression or symptoms measured on a validated scale.
 36 1 75 -0.152 0.170 37 -0.079 0.209 39 -0.152 0.372
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Crime Criminal justice system $21,292 $0 $40,482 $10,646 $72,421
Major depressive disorder Labor market earnings associated with major depression $902 $2,124 $0 $0 $3,026
Health care associated with major depression $658 $186 $680 $329 $1,853
Mortality associated with depression $2 $6 $0 $206 $214
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($1,408) ($1,408)
Totals $22,855 $2,316 $41,161 $9,774 $76,106
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Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $2,816 2023 Present value of net program costs (in 2023 dollars) ($2,816)
Comparison costs $0 2023 Cost range (+ or -) 10%
The per-participant cost estimate for in-prison TC treatment was provided by the Washington State Department of Corrections. The estimate is based on delivering an 832-hour program (four hours per day, four days per week) at a rate of $51 per hour (salary and benefits) for DOC Program Specialist staff delivering this program. It assumes an average group size of 15.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

McKendrick, K., Sullivan, C., Banks, S., & Sacks, S. (2006). Modified therapeutic community treatment for offenders with MICA disorders: Antisocial personality disorder and treatment outcomes. Journal of Offender Rehabilitation, 44(2-3), 133-159.

Sacks, S., Sacks, J.Y., McKendrick, K., Banks, S., & Stommel, J. (2004). Modified TC for MICA offenders: Crime outcomes. Behavioral Sciences and the Law, 22(4), 477-501.

Sullivan, C.J., Sacks, S., McKendrick, K., Banks, S., Sacks, J.Y., & Stommel, J. (2007). Modified therapeutic community treatment for offenders with co-occurring disorders: Mental health outcomes. Journal of Offender Rehabilitation, 45(1-2), 227-247.