Drug Treatment Centers
Correlates of therapeutic involvement among adolescents in residential drug treatmentJosephine M. Hawke INTRODUCTION
Adolescents are notoriously difficult to engage and retain in treatment, which is documented by several studies (1-5) that report high dropout rates for adolescents in treatment. Compared to adults, adolescents also may require longer treatment tenures to produce similar positive treatment outcomes e.g., Burkstein (6), Hubbard et al. (2) Jainchill et al. (7), Sells and Simpson (4), Brown et al. (8). These findings underscore the need to understand the factors that affect the early engagement of adolescents in the therapeutic process.
Relatively few studies have examined treatment process among adolescents in residential drug treatment, especially those with severe psychiatric symptoms--see reviews by Burkstein (6), Catalano et al. (9), Lipsey and Wilson (10), Weisz et al. (11), Williams and Chang (5). As a result, there is a critical need for research on the therapeutic involvement (TI) among adolescent substance users in treatment. Toward this end, the current study reports on the psychometric properties of measures of therapeutic involvement that were derived from therapeutic involvement scales that have been widely used among adults and examines the correlates of therapeutic involvement among a sample of adolescents in residential drug treatment.
Therapeutic involvement and the services that clients receive during treatment are among the best predictors of treatment retention and are associated through retention to posttreatment outcomes. Models of therapeutic involvement in treatment link higher levels of therapeutic involvement to increased odds of client retention and better posttreatment outcomes, e.g., De Leon et al. (12), Joe et al. (13), Simpson et al. (14). However, most theoretical models of therapeutic involvement and treatment progress, as well as how to measure concepts like treatment engagement and counselor rapport, have stemmed from research on adult populations. Studies of adolescent populations that use proxies of therapeutic involvement such as overall treatment service intensity, types of services, unmet needs, counselor rapport, and satisfaction with treatment to examine the treatment process also find similar results among youths, e.g., Hser et al. (15).
Conceptually, therapeutic involvement refers to clients' active engagement in the therapeutic process and acceptance of their own contributions to problem maintenance and resolution. Therapeutic involvement facilitates the recovery process. Clients who participate more fully in the therapeutic process develop key recovery skills such as emotional self-regulation, effective coping, and better understanding of self--factors critical to a successful recovery process, see Winters (16). Another aspect of therapeutic involvement includes feeling a positive rapport with treatment staff; as clients become more involved in the therapeutic process, they are more likely to become more trusting of their counselors and consequently engage more in the program and its staff. Therapeutic involvement is related to other client factors that are associated with client treatment, engagement, and retention, such as gender, psychiatric symptoms, drug use severity, self-esteem, and family characteristics (6, 15-22). Joe et al. (13) found that adolescents who reported more social support at entry to residential drug treatment exhibited significantly higher levels of therapeutic involvement during treatment. Other studies document the positive impact of better social supports on treatment retention and posttreatment outcomes, e.g., Coughey et al. (23), Richter et al. (24), Siddall and Conway (25), Simpson et al. (14).
METHOD
Procedures
Data for the study was derived from a survey of 185 adolescent clients in five adolescent residential drug treatment programs in New Jersey. All current clients were recruited for survey participation at all the programs. Data collection took place during site visits during August and September of 2002 using a group format to minimize the level of disruption to regularly scheduled program activities. All potential survey recruits received a written description of the study and an explanation of their rights vis-a-vis participation. Study descriptions detailed risks related to participation, the procedures that were undertaken to protect participants' rights and confidentiality, and clearly stated that participation was voluntary. Since no names or other identifying information (e.g., treatment identification numbers) were gathered on participants, it was not necessary to obtain informed consent/assent from staff, clients, or guardians as described in the guidelines of the U.S. Department of Health and Human Services. Participants were further assured that data would be reported in aggregate form only, so that program staff, supervisors, and other interested parties could not identify individual participants. Although the survey was voluntary, almost all the clients participated. Client participation rates varied from 87% to 100% across the programs.
Program Sites
Five residential drug treatment programs in New Jersey participated in the study. Programs included one community-based program for adolescent males and females located in New Jersey and four residential programs operated by the State of New Jersey's Juvenile Justice Commission (JJC). All five programs subscribe to a modified treatment community (TC) approach to treat adolescents (26-29) with a heavy emphasis on cognitive-behavioral therapeutic techniques.
The community-based treatment program serves adolescent substance abusers between 13 and 18 years of age. At the time of the survey, there was a total of 60 beds, half of which were designated for females. The program is funded in part by the New Jersey Department of Health and has beds set aside for juveniles mandated to treatment by the justice system. The planned duration of treatment varies from two to 12 months, depending on the type of referral. Treatment consists of a range of mental health and educational services, including individualized treatment plans that incorporate group and individualized counseling, life skills training, and high school and general education diploma (GED) courses.
The JJC is responsible for the care and custody of juvenile offenders committed to the agency by the courts and the supervision of youth on juvenile parole. Three of the programs that participated in the survey are residential community homes operated by the JJC and one is a therapeutic community for incarcerated adolescent males. Residential community homes accommodate juveniles who have committed less serious offenses or are nearing the end of their sentence and preparing to return home. The JJC programs provide educational and vocational training, in addition to substance abuse treatment. Counselors work with residents to create individualized treatment plans that include developing an understanding of the triggers and underlying causes of substance use, preventing relapse, completing high school equivalency, and developing marketable skills. The three participating JJC residential community homes included a 40-bed residential TC program for substance-abusing adolescent males between 16 and 18 years of age, a 12-bed TC program for adjudicated females between the ages of 13 and 18 years of age, and a 30-bed drug treatment program for adjudicated males between 16 and 18 years of age. In addition, clients in a 40-bed residential TC for incarcerated adolescent males participated. Like the community homes, the program for incarcerated males provides both substance-abuse treatment and education-vocational training.
Subjects
The sample consisted of N=180 youths in residential drug treatment. Seventy-nine percent were male, 20% were Hispanic, 36% were African-American and 46% were Caucasian. The majority of subjects (85%) was between 16 and 18 years of age, with an average age of 17 years. Twenty-four percent had completed high school or obtained a GED and 15% had less than an eighth grade education. Subjects exhibited clinical to acute levels of internalizing and externalizing psychiatric symptoms and substance use as assessed by the Global Appraisal of Individual Needs (GAIN-QS) (30). Rates of delinquency were high; 80% reported regularly cutting school or work, 66% were suspended or expelled from school, and almost 60% reported physically attacking another person in the last year. Over 80% also reported being arrested in the last year. Similarly, there were high prevalence rates for internalizing psychiatric symptoms among the subjects. In particular, symptom rates for anxiety were high; 87.3% of the clients required further clinical assessment for anxiety disorders.
Measurement
A Client Survey Questionnaire (CSQ) developed for the survey contains scales to measure relevant client drug use, criminal activity, and socio-psychological characteristics from the GAIN-QS. The GAIN-QS was supplemented with selected scales to measure relevant client characteristics and therapeutic involvement.
Client Characteristics
The GAIN-QS was used to obtain a wide range of client characteristics. It is a standardized clinical screen normed for both adults and adolescents, see Dennis et al. (31), Dennis (32). The GAIN-QS uses a serf-report format to assess internalizing behaviors (Internal Distress, Suicidality, and Anxiety), externalizing behaviors (Attention-Deficit-Hyperactivity Disorder, Conduct Disorder, and General Criminality), and drug use (Substance Use and Abuse and Substance Dependence). Core symptoms refer to behaviors that occurred during the past year. Previous research indicates that Cronbach's alphas for adolescent clients on the scales range from .63 for substance use and abuse to .82 for the anxiety scale (32). Scoring of the GAIN-QS resulted in scale scores ranging from 0 to 100 that were categorized into four quartile groups as described in the GAIN-QS manual. Although scores do not represent diagnoses, they do suggest the distribution of need and symptom severity within the client populations. The preliminary analyses examined correlations among all the GAIN measures. However, only data on client demographic characteristics and scores that measure Substance Use Problems and General Deviance were found relevant for the current analyses.
Self-Esteem and Self-Efficacy
Scores from the Client Evaluation of Self and Treatment Scales (CEST) were used to assess the client's self-esteem and general self-efficacy among clients. Self-efficacy measures the client's belief that he or she has the ability to control things or has the power to solve problems in her/his life. Self-esteem evaluates whether the client perceives herself or himself in a positive way. Score scales ranged from 0 to 100, with higher scores on each scale representing more of the attribute. The average client self-esteem score was 81.81 (sd=20.49) and the average self-efficacy score was 69.81 (sd=12.29).
Spirituality
The Personal Experience Inventory (PEI) (33), items for the Spiritual Isolation Scale were recoded to measure the client's spirituality and scores were standardized to range from 0 to 100. High scores represented the tendency to turn to prayer or meditation in times of distress and a belief in a higher power. The average client score was 61.50 (sd=20.02).
Therapeutic Involvement Measures
Items from four widely used measures of therapeutic involvement in studies of adults were utilized to assess adolescent therapeutic involvement (Table 1). These measures were the Treatment Participation scale from the Client Evaluation of Self and Treatment Scales (CEST) (34), and the 5-item Counselor Rapport measure from the Drug Abuse Treatment Outcome Study (DATOS) (13). Retention and patient engagement models for the client instrument were also based on the CEST. The Working Alliance Inventory (WAI), see Horvath and Greenberg (35), was to measure the quality of the therapeutic or working alliance. Items from the WAI (Client Form) include, "I believe (my counselor) is genuinely concerned with my welfare," and "I am confident in (my counselor's) ability to help me." Reliability for the client version is a reported alpha of .93 and for the counselor version, .87. Subscale alphas range from .68 to .92. Good convergent, concurrent, and predictive validities are reported. Item responses are coded as 1=strongly disagree, 2=disagree, 3=not sure, 4=agree, and 5=strongly agree on all three scales. These scales have been widely utilized and exhibit psychometric properties with adult substance-abusing populations.
Data Analysis
Psychometric Properties
One purpose of the current analysis is to demonstrate the appropriateness of the TI measures for assessing therapeutic involvement among adolescent clients. Because adolescents often lack the attention spans or willingness to complete lengthy assessments during treatment, a secondary goal was to develop the parsimonious measures of TI. Therefore, the data analytic strategy that involved using factor analyses used maximum likelihood extraction and oblique rotation to examine the amount of variance explained by the scale items and potential multidimensionality. Oblique rotation provides an accurate representation of how factors are likely to be related to one another since it does not assume independence, in contrast to Varimax rotation, see Fabrigar et al. (36). First, factor analyses were conducted on all items from the TI scales to examine cross-loadings among the variables. Second, separate factor analyses were conducted on items for each factor with an eigenvalue of 1.00 or greater. Variables in these analyses included those with factor loadings at or exceeding .36. When variables cross-loaded on two or more factors, the variable was included for which it was most theoretically consistent and/or on which it had the highest loading. Variables with loadings less that .36 in the second set of factor analyses were eliminated. Additionally, confirmatory factor analysis was performed to address the dimensionality of each scale and separateness among the scales. Theses analyses relied on AMOS computer software (37) and model fit statistics reported include the Normed Fit Index (NFI), the Tucker-Lewis Index (TLI), and the Adjusted Global Fit Index (AGFI) are used to evaluate the fit of the confirmatory factor analytical models. Values for each index range from 0 to 1. Values close to 1 are desirable and indicate better fit. Finally, Cronbach's alpha coefficients were used to examine internal consistency of the resulting scales. Coefficients of reliability range from 0 to 1. Higher coefficients indicate more internal consistency among scale items. Generally, scales with Cronbach's alphas of .70 suggest adequate levels and scores of .80 or more imply good to excellent levels of internal consistency.
Correlates of Therapeutic Involvement
Pearson's correlation coefficients were used to compare the relationship between variables and multivariate linear regression was employed to examine the correlates of therapeutic involvement. Each measure of therapeutic involvement was regressed on a set of standard client characteristics. This set included gender, age, race-ethnicity, family functioning, spiritualism, and GAIN-QS scores for substance abuse problems severity, psychiatric problem severity, and a dummy variable representing Daytop-NJ membership. The measures are described more fully in Section 3 of this report. Due to the relatively small sample of clients across all five programs (N=185), the analysis looked at correlates of therapeutic involvement among all clients surveyed, rather than among specific programs. The categorical variable identifying whether the client was in the community-based TC program represents a test of the effect of program membership. The advantage of multiple regression techniques over simply comparing averages across client characteristics is that the results indicate the unique contribution of the client characteristic on the prediction of levels of therapeutic involvement scores after controlling for other significant variables in the analysis.
RESULTS
Psychometric Properties
Table 2 describes the psychometric properties of the abbreviated TI scales. Three scales emerged: 1) Therapeutic Engagement (TE) based on the CEST Treatment Participation items, 2) Counselor Rapport (CR) based on the DATOS items, and 3) the Working Alliance (WA) scale which was comprised of five of the six original WA items. In each case, the results of the confirmatory factor analysis indicate that the abbreviated version fit better than the original version. Cronbach's alpha coefficients and principal axis factor analysis of each scale also suggests good comparability of the long and short versions. Therefore, the following analyses are based on the abbreviate scales scores.
Client Correlates of Therapeutic Involvement
Tables 3 and 4 show the bivariate and multivariate correlations of therapeutic involvement, respectively. The three measures of therapeutic involvement were significantly correlated with each other. Both TE and CR had a bivariate correlation coefficient of .74. However, TE and CR were only moderately correlated with WA. Due to this pattern of intercorrelation and concerns about multicollinearity, only WA was entered in the multivariate analyses predicting TE and CR. Separate analyses were conducted for WA with TE and CR as potential correlates.
A limited number of client characteristics were associated with each measure of therapeutic involvement. Clients who reported more positive working relationships with their primary counselors, who had better self-esteem, and who reported higher levels of spirituality, higher scores on the general deviance index, and lower scores on the substance use problems index exhibited more TE. Females tended to report better TE and African-Americans were most likely to report lower TE. A client's CR was most strongly associated with having better scores on working alliance, self-esteem, spirituality, being female, and having more substance abuse problems. Finally, WA was related only to the clients' demographic characteristics and CR.
DISCUSSION
There were important limitations to the study. All data were self-reported and as such were subject to the limitations of self-report data in general. The quality of the data depends on the ability of respondents to observe, reflect on, and report on the phenomenon in question and their willingness to do so. Adolescents in drug treatment can been suspicious about the true intent of research and are likely to express resistance by providing arbitrary or inconsistent responses, particularly under the guise of anonymity that the current research offered. The degree to which these factors influenced the results is unknown. Although response patterns of missing data suggested some variation in the quality of the data across programs, no youths were coerced into completing the questionnaire and the overall participation rate was 87% or greater across programs. In debriefings that took place after completion of the survey, clients indicated that they welcomed the opportunity to express their feelings about their treatment experiences. Another limitation is that the study collected information on a limited number of programs that are not necessarily representative of adolescent treatment programs in general, programs in the State of New Jersey, or programs affiliated with the Juvenile Justice Commission. Ideally, self-report data on therapeutic involvement should be cross-validated with reports from counselors and/or other clients in the program and should be collected at a larger number of programs.
Despite these limitations, the study provided a unique first look at important programs and client-level characteristics of the five programs. Unfortunately, there are no program norms for therapeutic involvement among adolescents in residential drug treatment programs.
This study demonstrates the utility of using brief measures of therapeutic involvement with adolescents in drug treatment. Adolescents often lack the attention span or willingness to complete paperwork that can facilitate treatment planning. As a result, the development of brief scales to assess therapeutic involvement improves the clinical utility of the scales. The study aimed to identify psychometrically sound measures of therapeutic involvement using items from scales that have been widely used with adult treatment populations and to examine the correlates of therapeutic involvement among adolescents.
Research on correlates of therapeutic involvement among adolescents is also quite limited. The multivariate analyses in this study identified gender, spirituality, self-esteem, and problem severity (deviance and substance use problems) as significant correlates of therapeutic involvement. In particular, self-esteem and spirituality were relatively strong correlates of all measures of therapeutic involvement after taking into consideration other factors. More research is needed that examines the interplay between self-esteem, spirituality, therapeutic involvement, and recovery among adolescents. This type of research can inform early induction strategies to promote better engagement in treatment services during the first few months of treatment when the risk for program dropout is highest.
Findings also indicate that there may be important subgroup differences. In particular, family functioning, abuse histories, gender, and ethnicity may differentially affect therapeutic involvement. For example, bivariate correlations suggest that abusive family relationships and family isolation may be moderated by gender and ethnicity. Both exhibited bivariate correlations with one or more of the measures of therapeutic involvement, although the correlations disappeared after taking into account other client characteristics. In particular, working alliance, which was closely related to therapeutic engagement and counselor rapport, was predicted largely by gender and ethnicity; females tended to report poor working alliances more than did males and compared to Caucasians, minorities reported better working relationships. Past research has illustrated the higher prevalence of abuse histories among females (20, 21, 38). Females in the current study were slightly more likely to report abusive family relationships. On the other hand, ethnic status, in particular being African-American, appears to be associated with many of the factors predictive of therapeutic involvement (e.g., self-esteem, working alliance, and problem severity) and inversely related to family isolation. Although the current study did not have sufficient statistical power to adequately examine subgroup differences, the findings may be indicative of the need for further research that assesses the moderating influence of gender and ethnicity on therapeutic involvement. Similarly, more rigorous analysis of the impact of comorbidity and trauma exposure may suggest the need for trauma-sensitive and or family-based interventions for some clients.
Table 1. Measures of therapeutic involvement
Therapeutic Engagement (TE)
1. I am willing to talk about my feelings during counseling.
2. I have learned to analyze and plan ways to solve my problems.
3. I am following my counselor's guidance.
4. I feel good about my progress working on my problems.
Counselor Rapport (CR)
1. My counselor supports my goals.
2. My counselor is sincere in wanting to help me.
3. I work well with my counselor.
4. This treatment meets or exceeds my expectations.
Working Alliance (WA)
1. My counselor has a clear idea of what my goals are.
2. My work with my counselor is important to me.
3. My counselor and I have reached a good understanding of the kinds of
changes that would be good for me.
4. My counselor and I are working towards goals that we both agree on.
5. I feel sure that my counselor is able to help me.
Table 2. Psychometric properties of TI scales
TE PC CR WA
NFI .99 .98 .99 .99
AGFI .95 .94 .93 .99
TFI .99 .97 .98 1.00
Chi square 2.92 3.97 4.64 2.06
df 2 2 2 5
Significance .232 .137 .098 .841
Total variance explained 57.00 40.58 65.28 72.78
Cronbach's alpha .84 .78 .87 .94
Table 3. Correlation matrix
1 2 3 4 5
1. TE --
2. CR .74 ** --
3. WA .31 ** .28 ** --
4. JJC program -- -- .55 ** --
5. Substance use probs -- .18 * -- .41 ** --
6. General crime -- -- -- -- .42 **
7. Spirituality .34 ** .28 ** .17 * -- --
8. Family isolation -- -- .22 ** .24 ** .32 **
9. Abusive relationships -.18 * -- -- -- --
10. Female .21 ** .24 ** -.18 * .41 ** .28 **
11. African American -- -- .17 * .40 ** .33 **
12. Hispanic -- -- .16 * .19 * --
13. Self-efficacy .28 ** .21 ** -- -- --
14. Self-esteem .32 ** -23.** -- -- .26 **
6 7 8 9
l. TE
2. CR
3. WA
4. JJC program
5. Substance use probs
6. General crime --
7. Spirituality -- --
8. Family isolation .32 * -- --
9. Abusive relationships -- -- .40 ** --
10. Female -- -- -- --
11. African American -- -- -.22 * --
12. Hispanic -- -- -- --
13. Self-efficacy -- -- -.18 * -.26 **
14. Self-esteem -.21 ** -- -.35 ** -.25 **
10 11 12 13
l. TE
2. CR
3. WA
4. JJC program
5. Substance use probs
6. General crime
7. Spirituality
8. Family isolation
9. Abusive relationships
10. Female --
11. African American -.21 ** --
12. Hispanic .17 * -- --
13. Self-efficacy -- -- -- --
14. Self-esteem -- .17 * -- .55 **
* p<.05.
** p<.001.
Table 4. Multivariate correlates of therapeutic involvement scores
TE CR WA
b [beta] b [beta] b [beta]
Female 1.85 .21 ** 2.23 .24 ** -3.91 -.27 **
African-American -1.37 -.17 * -.78 -.10 2.52 .20 **
Hispanic -.08 -.01 -.74 -.08 3.51 .24 **
Substance .03 .20 * .03 .21 * -.01 -.05
use problems
General deviance -.02 -.20 ** -.01 -.06 -.01 -.06
index
Spirituality .05 .25 ** .04 .20 ** .02 .05
Self-Esteem .07 .34 ** .07 .30 ** -.05 -.13
Working .21 .33 ** .23 .36 ** -- --
Alliance (WA)
Counselor -- -- -- -- .62 .39 **
Rapport (CR)
Constant 3.44 3.18 9.60
[F.sub.8,146] 12.44 p=.000 8.97 p=.000 6.54 p=.000
Adjusted R square .37 .29 .22
Standard error 2.97 3.19 5.23
* p<.05.
** p<.001.
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Josephine M. Hawke, Ph.D.
The National Development and Research Institutes, Inc.,
New York, New York, USA
Joseph Hennen
The Daytop Adolescent Substance Abuse Program in New Jersey,
Mendham, New Jersey, USA
Peter Gallione
New Jersey's Juvenile Justice Commission, Bordontown,
New Jersey, USA
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