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National Institute on Drug Abuse -  NIDA NOTES
Treatment Research
Volume 12, Number 4
July/August 1997

In New York City

Peer Community Helps Homeless Drug Abusers With Mental Illnesses Reduce Drug Use

By Neil Swan, NIDA NOTES Staff Writer

"I made good friends here. I call them family . . . . Even the staff, they are my family. They gave me suggestions, ideas, looking to my future. They helped me. . . . I had 2 years of college, but I didn't get anything out of it. I was using [crack]. . . . I see myself with a future now. . . . Now I want to work for my money. I plan to get my children back, and I am seeking housing for me and my children."

- Sarah, a graduate of a program in New York City for homeless, mentally ill substance abusers

Researchers at the Center for Therapeutic Community Research (CTCR) in New York City, one of NIDA's major multidisciplinary research centers, are studying a treatment program they devised to meet the complex psychiatric and substance abuse needs of homeless substance abusers who are also mentally ill. They have designed a "modified therapeutic community (TC)" that provides 24-hour-a-day supervised residential treatment for 12 months or more followed by less intense aftercare in which patients live alone or together in apartments and hold down jobs.

Patients are recruited into the program by counselors at New York City homeless shelters and psychiatric facilities. Staff members, some of them former homeless substance abusers themselves, help make the program attractive to the homeless. The NIDA-funded treatment research was conducted by the Center at the National Development and Research Institutes. Led by CTCR director Dr. George De Leon, the research has shown that the modified TC program can be effective in treating this elusive population that has "fallen through the cracks" in traditional treatment approaches. Patients substantially reduce drug use and criminal behavior following treatment and also find and keep jobs more frequently than before treatment.

This program for homeless, mentally ill substance
abusers can be effective in treating an elusive
population that has "fallen through the cracks" in
traditional treatment approaches.

The original TC approach was developed to treat serious substance abusers in a residential program by changing their behavior and thinking. Support of the treatment program members - peers and counselors - is a key ingredient of TCs, which have been enhanced over the years with additional services for vocational, medical, family, and other needs. Today's TC has more participation from mental health, medical, and education professionals who serve along with TC paraprofessionals who are trained recovered addicts.

The TC approach, according to Dr. De Leon and his colleagues, views substance abuse as a disorder of the whole person. Thus the approach provides a combination of social and psychological therapy that fosters change in patients' behavior, attitudes, feelings, and values. Individuals are motivated to change through their interaction with others, including their peers from the streets. The New York City research is built on a concept of "community as method," which uses the treatment community itself and its activities, relationships, and expectations to enable patients to learn about and change themselves.

Dr. Stanley Sacks, CTCR's deputy director, explains that the resident community, which usually consists of 12 to 20 patients, provides a structured daily regimen with morning and evening community meetings, seminars, classes, conflict-resolution therapy sessions, and a peer work structure in which community members maintain the facility and prepare their meals. The residents progress toward reentry into society by moving first through a transitional program in which they share apartments with other patients. Mutual support and community ties are continued while patients advance toward entering the job market. Some are employed in clerical or maintenance positions; others eventually become peer counselors in similar recovery programs. After 6 to 12 months of transitional apartment living - 18 to 24 months after entering the residential program - patients advance to independent living while maintaining kinship ties with peers and holding jobs.

The CTCR study profiled 342 homeless patients as they entered the modified TC program. Interviews by CTCR researchers showed that the fundamental needs of the patients were extensive, combining psychiatric, substance abuse, medical, and social problems that were acute and intricately intertwined. The patients interviewed were three-quarters male and 70 percent African-American, with a median age of 35. The researchers found that 99 percent reported illegal drug use some time in their lives; 24 percent reported injecting drugs. Half reported crack or cocaine as their primary drug of abuse; 22 percent cited alcohol and 16 percent identified marijuana as their secondary substance of abuse. Some 84 percent of the patients had not had a job in the past year. Four in 10 said they had had difficulty throughout their lives in making and keeping friends. Virtually all, 99 percent, of the patients reported past criminal activity, and 81 percent said they had broken the law in the past year. Three-quarters of the patients said they had been tested for infection with HIV, the AIDS virus, and 10 percent reported positive HIV test results.

Using a standardized diagnostic test, the researchers also found that 60 percent of their patients had one or more serious mental illnesses - 38 percent were diagnosed with major depression, 34 percent with schizophrenia, and 13 percent with mania. When other mental disorders such as posttraumatic stress disorder and phobia were included, 82 per-cent of the patients had diagnoses of serious mental illness.

The modified TC targets treatment to meet these multidimensional needs. Compared to standard TC programs, treatment interventions are more individualized, more flexible, and less intense, explains Dr. Sacks. However, the program remains grounded in peer interactions and the "community as method" concept to foster change, he says.

The fundamental needs of the patients were
extensive, combining psychiatric, substance
abuse, medical, and social problems that
were acute and intricately intertwined.

Even in the face of the homeless patients' severe and accumulated problems, the modifications to the TC model are proving effective, initial treatment outcome data indicate. Patients in modified TCs had more successful outcomes at followup, an average of 750 days after entering treatment, than did other New York patients with similar diagnoses who were enrolled in more conventional treatment programs. Those in modified TC treatment reported less illegal drug use and less criminal activity and showed greater improvement on tests to evaluate depression compared with the conventional treatment patients. In addition, those in modified TC showed important gains in employment levels compared with their pretreatment levels. (See "Changes in Outcomes After Treatment," at bottom of page)

Aftercare is critical for these patients as they progress toward independent living, says Dr. De Leon. Mental health and medical needs are the most pressing, he adds. Patients who enter treatment with a long history of severe drug abuse - 10 years or more - and psychiatric problems require more time than do others in the program, he says. But it may be possible to shorten the time in the residential setting with improved aftercare services, he adds.

Changes in Outcomes After Treatment*
(Measured an Average of 750 Days After Patients Entered Treatment)

Currently, NIDA is supporting a CTCR study to examine the cost-effectiveness of the modified TC program. This study is evaluating program costs against benefits to society measured in taxpayer savings through reduced crime and social services expenditures and increased tax revenues as patients become productive wage-earners. Also with NIDA funding, CTCR is evaluating a modified TC for mentally ill substance abusers in the San Carlos Correctional Facility in Pueblo, Colorado.


De Leon, G. Modified therapeutic communities for dual disorder. In: J. Solomon, S. Zimberg, and E. Shollar (Eds.), Dual Diagnosis: Evaluation, Treatment, and Training. New York, Plenum Press, 1993.

De Leon, G. Therapeutic communities for addictions: A theoretical framework. The International Journal of the Addictions 30(12):1603-45, 1995.

Sacks, S.; De Leon, G. Modified therapeutic community for homeless MICAs [mentally ill chemical abusers]: profiles, process and outcomes. Paper presented at the American Psychological Association annual meeting, Chicago, 1997.


Homeless mentally ill patients in a modified therapeutic community in New York City who were treated for both substance abuse and psychiatric problems had more successful outcomes after treatment than did patients with similar disorders in other treatment programs.


From NIDA NOTES, July/August 1997

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