Milieu therapy – Therapeutic community

Milieu therapy or therapeutic community is a collective term for various treatment methods based on a psychological theory of how collective activities in the physical and social environment can be used to treat illness, practice skills, provide self-insight and develop new patterns of action, in people with mental disorders or problems with addiction and crime. The method is based on participants taking part in the treatment of themselves, as well as in the treatment of others in a care ward or a treatment home, which functions as a therapeutic community.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: Report no: ut202214 Registration no: SBU 2020/705

Question

What scientific studies are there on milieu therapy/therapeutic community in institutional care, youth care or substance abuse treatment?

Identified literature

Table 1. Systematic reviews with low/moderate risk of bias
CBT = Cognitive behavioural therapy; CI = Confidence interval; RCT = Randomised controlled trial; RR = Relative risk; TC = Therapeutic community
Included studies Population/Intervention Outcome/Result
Magor-Blatch et al, 2014, [1]
A systematic review of studies examining effectiveness of therapeutic communities.
11 studies
Randomised or quasi-randomised controlled trials of TC intervention with follow-up of at least 6 months		 Population:
Adult substance-users

Intervention:
Residential therapeutic community treatment		 TC vs no treatment or other treatment group
Substance-use, crime, mental health:
No meta-analysis performed
Outcomes varied across studies but indicated reductions in substance-use and criminal activity
Increased improvement in mental health and social engagement
Authors' conclusion:
“Consistent with previous systematic reviews of TCs, outcomes varied across studies but indicated TCs are generally effective as a treatment intervention, with reductions in substance-use and criminal activity, and increased improvement in mental health and social engagement evident in a number of studies reviewed.”
Perry et al,2019a, [2]
Interventions for drug-using offenders with co-occurring mental health problems.
13 RCT
(4 using TCs)		 Population:
People involved in the criminal justice system with co-occurring mental health problems and drug misuse problems
Intervention:
Any pharmacological or psychosocial intervention		 TC vs treatment as usual
Re-arrest (2 studies, 266 participants):
RR 0.67 (95% CI, 0.53 to 0.84)
Moderate certainty of evidence
Return to prison (2 studies, 266 participants):
RR 0.4 (95% CI, 0.24 to 0.67)
Moderate certainty of evidence

TC vs CBT
Self-reported drug use, re-arrest, criminal activity, and drug related crime (1 study, 314 participants):
Very low certainty of the evidence

TC vs waiting list:
Return to prison (1 study, 478 participants):
RR 0.60 (95% CI 0.46 to 0.79)
Moderate certainty of the evidence
Authors' conclusion:
“Therapeutic community interventions and mental health treatment courts may help people to reduce subsequent drug use and/or criminal activity.”
Perry et al, 2019b, [3]
Interventions for female drug‐using offenders.
13 RCT
(2 using TCs)		 Population:
Females involved in the criminal justice system with drug misuse problems

Intervention:
Any pharmacological or psychosocial intervention		 TC vs work release
Self-reported drug use. No significant difference (1 study, 28–211 participants):
Very low certainty of evidence

TC vs CBT
Self-reported drug use, arrest, criminal activity, or drug related crime:
No significant difference after 6 months.

Subsequent arrest (not parole) violations (1 study 314 participants):
A significant difference in favour of cognitive behavioural therapy.
Very low certainty of evidence

Reincarceration after 12 months (1 study 115 participants):
No significant difference
Low certainty of evidence
Authors' conclusion:
“The studies showed a high degree of heterogeneity for types of comparisons, outcome measures and small samples. Descriptions of treatment modalities are required. On one outcome of arrest (no parole violations), we identified a significant reduction when cognitive behavioural therapy (CBT) was compared to a therapeutic community programme. But for all other outcomes, none of the interventions were effective. Larger trials are required to increase the precision of confidence about the certainty of evidence.”

Twelve primary studies were also identified [4–15]. The primary studies were not assessed for risk of bias.

References

  1. Magor-Blatch L, Bhullar N, Thomson B, Thorsteinsson E. A systematic review of studies examining effectiveness of therapeutic communities. Ther Communities. 2014;35(4):168-84. Available from: https://doi.org/10.1108/tc-07-2013-0024.
  2. Perry A, Martyn‐St JM, Burns L, Hewitt C, Glanville J, Aboaja A, et al. Interventions for female drug‐using offenders. Cochrane Database Syst Rev. 2019; (12). Available from: http://dx.doi.org/10.1002/14651858.CD010910.pub3.
  3. Perry AE, Martyn-St James M, Burns L, Hewitt C, Glanville JM, Aboaja A, et al. Interventions for drug-using offenders with co-occurring mental health problems. Cochrane Database Syst Rev. 2019;10(10):CD010901. Available from: https://doi.org/10.1002/14651858.CD010901.pub3.
  4. Amani M, Saemian H, Rezvan-Doust H. Comparison of Residential and Therapeutic Community Centers in Preventing Substance Abuse Recurrence and Reducing Self-destructive Behaviors of Substance Users. Addict Health. 2019;11(1):43-50. Available from: https://doi.org/10.22122/ahj.v11i1.227.
  5. Babaie E, Razeghi N. Comparing the effects of methadone maintenance treatment, therapeutic community, and residential rehabilitation on quality of life and mental health of drug addicts. Addict Health. 2013;5(1-2):16-20.
  6. Bale RN, Van Stone WW, Kuldau JM, Engelsing TM, Elashoff RM, Zarcone VP, Jr. Therapeutic communities vs methadone maintenance. A prospective controlled study of narcotic addiction treatment: design and one-year follow-up. Arch Gen Psychiatry. 1980;37(2):179-93. Available from: https://doi.org/10.1001/archpsyc.1980.01780150069008.
  7. Bevanda D, Tomić I, Bevanda M, Skočibušić S, Palameta N, Martinac M. The differences in Quality of Life between the Heroin Addicts treated in Methadone Program and Addicts treated in the Frame of Therapeutic Community Program. Alcoholism and Psychiatry Research. 2017;53(1):17-26. Available from: https://doi.org/10.20471/apr.2017.53.01.02.
  8. De Leon G, Sacks S, Staines G, McKendrick K. Modified therapeutic community for homeless mentally ill chemical abusers: treatment outcomes. Am J Drug Alcohol Abuse. 2000;26(3):461-80. Available from: https://doi.org/10.1081/ada-100100256.
  9. Inciardi JA, Martin SS, Butzin CA, Hooper RM, Harrison LD. An Effective Model of Prison-Based Treatment for Drug-Involved Offenders. Journal of Drug Issues. 1997;27(2):261-78. Available from: https://doi.org/10.1177/002204269702700206.
  10. Jason LA, Olson BD, Harvey R. Evaluating Alternative Aftercare Models for Ex-Offenders. J Drug Issues. 2015;45(1):53-68. Available from: https://doi.org/10.1177/0022042614552019.
  11. Majer JM, Chapman HM, Jason LA. Comparative Analysis of Treatment Conditions upon Psychiatric Severity Levels at Two Years Among Justice Involved Persons. Adv Dual Diagn. 2016;9(1):38-47. Available from: https://doi.org/10.1108/ADD-07-2015-0015.
  12. Morral AR, McCaffrey DF, Ridgeway G. Effectiveness of community-based treatment for substance-abusing adolescents: 12-month outcomes of youths entering phoenix academy or alternative probation dispositions. Psychol Addict Behav. 2004;18(3):257-68. Available from: https://doi.org/10.1037/0893-164X.18.3.257.
  13. Herbert J. Hormones and behaviour. Proc R Soc Lond B Biol Sci. 1977;199(1136):425-43. Available from: https://doi.org/10.1098/rspb.1977.0152.
  14. Pearce S, Scott L, Attwood G, Saunders K, Dean M, De Ridder R, et al. Democratic therapeutic community treatment for personality disorder: randomised controlled trial. Br J Psychiatry. 2017;210(2):149-56. Available from: https://doi.org/10.1192/bjp.bp.116.184366.
  15. Wexler HK, Falkin GP, Lipton DS. Outcome Evaluation of a Prison Therapeutic Community for Substance Abuse Treatment. Crim Justice Behav. 2016;17(1):71-92. Available from: https://doi.org/10.1177/0093854890017001006.

Literature search

PubMed via NLM 30 November 2021

Milieu therapy /therapeutic community for substance abuse, young offenders or institutional care

The search result, usually found at the end of the documentation, forms the list of abstracts

[MeSH] = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; [MeSH:NoExp] = Does not include terms found below this term in the MeSH hierarchy; [MAJR] = MeSH Major Topic; [TIAB] = Title or abstract; [TI] = Title; [AU] = Author; [TW] = Text Word; Systematic[SB] = Filter for retrieving systematic reviews; * = Truncation
  Search terms Items found
Population:
1. "Substance Abuse Treatment Centers"[Mesh] OR alcoholism[tiab] OR alcoholics[tiab] OR substance-related disorders[MeSH] OR "Residential Treatment"[Mesh] OR “Residential care”[tiab] OR Residential treatment*[tiab] OR residential institution*[tiab] OR Residential setting*[tiab] OR ((abuse[tiab] OR misuse[tiab] OR dependence[tiab] OR addiction[tiab] OR use[tiab]) AND (drug[tiab] OR substance[tiab] OR alcohol[tiab])) 652 227
2. "Juvenile Delinquency"[Mesh] OR “youth care”[tiab] OR "young offender"[tiab] OR "young offenders"[tiab] OR "juvenile justice”[tiab] 9 476
3. Institution*[tiab] OR Inpatient*[tiab] OR "Inpatients"[Mesh] OR Hospitals, Psychiatric[MeSH] 471 102
Intervention:
4. “Milieu Therapeutic Treatment”[tiab] OR “Therapeutic Community”[tiab] OR “Therapeutic Milieu”[tiab] OR “Therapeutic collective”[tiab] OR “Situational Therapy”[tiab] OR "Milieu Therapy"[Mesh] OR "Milieu Therapy"[tiab] OR “Therapeutic Communities”[tiab] 3 583
Combined sets:
5. 1 OR 2 OR 3 1 106 434
6. 4 AND 5 2 200
Final  6 2 200

Cochrane Library via Wiley 30 November 2021

Milieu therapy/therapeutic community for substance abuse, young offenders or institutional care

The search result, usually found at the end of the documentation, forms the list of abstracts

au = Author; MeSH = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; this term only = Does not include terms found below this term in the MeSH hierarchy; :ti = Title; :ab = Abstract; :kw = Keyword; * = Truncation; “ “ = Citation Marks; searches for an exact phrase

CDSR = Cochrane Database of Systematic Review;CENTRAL = Cochrane Central Register of Controlled Trials, “trials”; CRM = Method Studies; DARE = Database Abstracts of Reviews of Effects, “other reviews”; EED = Economic Evaluations; HTA = Health Technology Assessments
  Search terms Items found
Population:
1. [mh "Residential Treatment"] OR “Residential care”:ti,ab,kw OR Residential treatment*:ti,ab,kw OR residential institution*:ti,ab,kw OR Residential setting*:ti,ab,kw OR [mh "Substance Abuse Treatment Centers"] OR alcoholism:ti,ab,kw OR alcoholics:ti,ab,kw OR [mh "substance-related disorders"] OR ((abuse:ti,ab,kw OR misuse:ti,ab,kw OR dependence:ti,ab,kw OR addiction:ti,ab,kw OR use:ti,ab,kw) AND (drug:ti,ab,kw OR substance:ti,ab,kw OR alcohol:ti,ab,kw)) 293 765
2. [mh "Juvenile Delinquency"] OR “youth care”:ti,ab,kw OR "young offender":ti,ab,kw OR "young offenders":ti,ab,kw OR "juvenile justice":ti,ab,kw 374
3. [mh "Inpatients"] OR [mh "Hospitals, Psychiatric"] OR Institution*:ti,ab,kw OR Inpatient*:ti,ab,kw 4 3078
Intervention:
4. “Milieu Therapeutic Treatment”:ti,ab,kw OR “Milieu Therapeutic Treatments”:ti,ab,kw OR “Therapeutic Community”:ti,ab,kw OR “Therapeutic Milieu”:ti,ab,kw OR “Therapeutic collective”:ti,ab,kw OR “Situational Therapy”:ti,ab,kw OR [mh "Milieu Therapy"] OR "Milieu Therapy":ti,ab,kw OR “Therapeutic Communities”:ti,ab,kw 204
Combined sets:
5. 1 OR 2 OR 3 328 104
6. 4 AND 5 138
Final 6 138

Embase via embase.com 30 November 2021

Milieu therapy/therapeutic community for substance abuse, young offenders or institutional care

/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ’ ’ = Citation Marks; searches for an exact phrase
  Search terms Items found
Population:
1. 'residential care'/exp OR “Residential care”:ti,ab,kw OR Residential treatment*:ti,ab,kw OR residential institution*:ti,ab,kw OR Residential setting*:ti,ab,kw OR 'residential home'/exp OR 'drug dependence treatment'/exp OR alcoholism:ti,ab,kw OR alcoholics:ti,ab,kw OR 'drug dependence'/exp OR ((abuse:ti,ab,kw OR misuse:ti,ab,kw OR dependence:ti,ab,kw OR addiction:ti,ab,kw OR use:ti,ab,kw) AND (drug:ti,ab,kw OR substance:ti,ab,kw OR alcohol:ti,ab,kw)) 842 103
2. 'juvenile delinquency'/exp OR “youth care”:ti,ab,kw OR "young offender":ti,ab,kw OR "young offenders":ti,ab,kw OR "juvenile justice”:ti,ab,kw 10 845
3. 'psychiatric department'/exp OR Institution*:ti,ab,kw OR Inpatient*:ti,ab,kw 719 707
Intervention:
4. 'milieu therapy'/exp OR “Milieu Therapeutic Treatment”:ti,ab,kw OR “Milieu Therapeutic Treatments”:ti,ab,kw OR “Therapeutic Community”:ti,ab,kw OR “Therapeutic Milieu”:ti,ab,kw OR “Therapeutic collective”:ti,ab,kw OR “Situational Therapy”:ti,ab,kw OR "Milieu Therapy":ti,ab,kw OR “Therapeutic Communities”:ti,ab,kw 3 898
Combined sets:
5. 1 OR 2 OR 3 1 532 505
16. 4 AND 5 1 605
Final 6 1 605

Databas Psychinfo, SocIndex och Psychology and behavioral sciences collection via ebsco.com 30 November 2021

Milieu therapy/therapeutic community for substance abuse, young offenders or institutional care

The search result, usually found at the end of the documentation, forms the list of abstracts

AB = Abstract; AU = Author; DE = Term from the thesaurus; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
  Search terms Items found
Population:
1. DE "Residential Care Institutions" OR DE "RESIDENTIAL substance abuse facilities" OR DE "Halfway Houses" OR DE "SOBER living environments" OR DE "Substance Use Treatment" OR DE "Alcohol Treatment" OR DE "SUBSTANCE abuse treatment" OR DE "ALCOHOLISM treatment" OR DE "DRUG abuse treatment" OR DE "DRUG rehabilitation programs for prisoners" OR DE "SUPPORT groups for substance abusers" OR DE "TREATMENT of drug addiction" OR DE "SUBSTANCE-induced disorders" OR DE "ALCOHOL-induced disorders" OR DE "Substance Related and Addictive Disorders" OR DE "Substance Use Disorder" OR DE "Substance Use Disorder" OR DE "Addiction" OR DE "Alcohol Use Disorder" OR DE "Cannabis Use Disorder" OR DE "Drug Abuse" OR DE "Drug Dependency" OR DE "Inhalant Abuse" OR DE "Opioid Use Disorder" OR TI (Residential treatment* OR residential institution* OR Residential setting* OR alcoholism OR alcoholics) OR AB ( “Residential care” OR Residential treatment* OR residential institution* OR Residential setting* OR alcoholism OR alcoholics) OR ((TI (abuse OR misuse OR dependence OR addiction OR use) OR AB (abuse OR misuse OR dependence OR addiction OR use)) AND (TI (drug OR substance OR alcohol) OR AB (drug OR substance OR alcohol))) 411 587
2. DE "Juvenile Delinquency" OR DE "Predelinquent Youth" OR TI (“youth care” OR "young offender" OR "young offenders" OR "juvenile justice”) OR AB (“youth care” OR "young offender" OR "young offenders" OR "juvenile justice”) 421 763
3. DE "Psychiatric Hospitals" OR DE "Psychiatric Units" OR TI (Institution* OR Inpatient*) OR AB (Institution* OR Inpatient*) OR DE "RESIDENTIAL mental health facilities" DE "PSYCHIATRIC hospitals" 348 175
Intervention:
4. DE "Milieu Therapy" OR DE "Therapeutic Community" OR DE "THERAPEUTIC communities" OR DE "MILIEU therapy" OR TI (“Milieu Therapeutic treatment” OR “Milieu Therapeutic treatments” OR “Therapeutic Community” OR “Therapeutic Milieu” OR “Therapeutic collective” OR “Situational Therapy” OR "Milieu Therapy" OR “Therapeutic Communities”) OR AB (“Milieu Therapeutic treatment” OR “Milieu Therapeutic treatments” OR “Therapeutic Community” OR “Therapeutic Milieu” OR “Therapeutic collective” OR “Situational Therapy” OR "Milieu Therapy" OR “Therapeutic Communities”) 7 845
Combined sets:
5. 1 OR 2 OR 3 767 034
6. 4 AND 5 3 875
Final 6 3 875
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