Is Long-term Residential Treatment Effective for Adolescents? a Treatment Outcome Study

There is a lack of research concerning the effectiveness of residential treatment for troubled adolescents. Due to a focus on internal controls in this area of research, there has been no conclusion as to how helpful such treatment is for real world clients. This is an effectiveness study that serves as a preliminary outcome evaluation for the Academy at Swift River, an emotional growth boarding school in Cummington, Massachusetts. Both the program graduates and their parents completed detailed questionnaires concerning the perceived behavior and attitude change of the patient. They were also given a standardized test by which the students could be compared to a national norm on the dimensions of clinical pathology and positive adaptation. Results found that the majority of pathological and adaptive behaviors were perceived to have improved by both the students and parents, but that the standardized measures of parent relations, selfreliance, conduct, and self-reported depression were still well within the clinical range. Despite these shortcomings, 100% of patients and their parents said that they would recommend treatment at ASR to others. Though much more research needs to be done in this field, this study lends support to the idea that residential treatment can be very effective for troubled adolescents. The History of Residential Treatment Centers in America Inpatient services, specifically intended for troubled adolescents, first began to appear in the United States in the 1920s (Kolko, 1992). Residential treatment centers are not simply facilities that offer basic residential care to dysfunctional populations, but rather a place of purposeful mental healing (Barker, 1988). The spread of such centers occurred based on the lack of outpatient services available at the time and the parental perception that they could not provide adequate assistance to their children who were in need of a trained specialist. Simultaneously, the ideas of the special needs student and of the therapeutic milieu also evolved and promoted the development of residential centers (Kolko, 1992). Milieu therapy was first applied to residential treatment centers for adolescents by Bettelheim at the University of Chicago upon his experience with a World War II concentration camp and his observation that the environment can contribute to the destruction of a personality. This realization changed the focus of treatment centers for youth from one of disciplinary control to one of an environmentally facilitated change (Zimmerman & Cohler, 2000) and promoted the growth of private facilities during the 1940s (Kolko, 1992). Prior to the 1950s, troubled adolescents were seen as too aggressive and destructive for less restrictive inpatient treatment (Pratt & Moreland, 1996). Colgate University Journal of the Sciences 155 Still, only a very small proportion of disturbed children and adolescents are placed into residential settings or inpatient units (Barker, 1974b). Current trends suggest that even fewer young people are placed in such settings today, but that there is an increase in their voluntary commitment, an increase in private sector support, and an increase in juvenile court referrals (Kolko, 1992). Most contemporary units are near their operating capacity. In 1990, there were approximately twenty-four specialized schools and programs for troubled youth outside of hospitals, and now the Educational Consultants Association lists two hundred fifty reputable programs with knowledge that there are hundreds of others available. These new smaller facilities are opening at the astonishing rate of three per month, dotting the West Coast, Southwest, and Northeast sections of our country (Rimer, 2001). It is now well documented that adolescents have greater improvements in facilities with other adolescents rather than in facilities with adults or children (Zimmerman & Sanders, 1988). The Adolescent Population at Residential Treatment Centers Young people are admitted to residential facilities when “a self-perpetuating cycle of dysfunctional behaviors is well established, and other less draconian, and less expensive, measures have failed.” (Barker, 1988, p.9) Male adolescents comprise 66% of residential treatment programs, with the mean age being 14.2 years (Zimmerman, 1998). Patients stay for an average of 5-22 months, and 94% are schooled on the premises. Conduct disorder is the most frequent diagnosis (56%), followed by affective disorders (46%), oppositional defiant disorder (29%), attention deficit disorder (24%), and posttraumatic stress syndrome (13%). Outside of the diagnosable disorders, frequently cited causes for admittance include family problems, peer problems, delinquency, property crimes, history of abuse, learning problems, drug and alcohol abuse, and violent tendencies (Kolko, 1992). The popular press in 2001 added sexual promiscuity, depression, bulimia, anorexia, bipolar disorders, and self-mutilation to the list, with the recent addition of the occasional compulsive computer hacker (Rimer, 2001). Combined inpatient samples of both hospital and residential patients average the 98 percentile on virtually all of the maladaptive scales of standardized tests, including measures of depression, hyperactivity, aggression, and conduct disorder (Jones et al., 1988). Benefits of Residential Treatment for Adolescents There are many advantages to treatment in a residential facility. As Wong (1999, p. 42) reports, “Adolescents with long-standing and intense aggressive, destructive, and disruptive behavior are not good candidates for short-term, outpatient, or in-home treatment. Simply put, youth in this state do not participate in or cooperate with therapy. Some type of extended residential or alternative living situation is probably necessary to provide a secure and controlled environment in which to instigate behavior change.” Inpatient care can provide immediate help in a crisis situation, and can remove the client from dangerous situations (Barker, 1974). More so than the average outpatient program, residential facilities offer more opportunities for therapeutic contact, more monitoring of dangerous and disturbing behaviors, and a more direct evaluation of aftercare options. Assessments that are hard to do as an outpatient can be done at these facilities, and at multiple intervals, and hence the reactions to medication and other interventions can be watched particularly closely. In fact, with a well-trained staff, all activities throughout Colgate University Journal of the Sciences 156 the day can be monitored for the sake of frequent reinforcement and constant therapeutic feedback (Kolko, 1992). Residential treatment centers can also cater to the needs of specific populations. The particular needs of adolescents usually differ in their means of communication and in their views of authority (Barker, 1974a). One of the biggest advantages of residential treatment is the freedom to use many different treatment modalities. No single treatment model could possibly help all troubled adolescents with their various backgrounds, personalities, and problems (Barker, 1988). Therapeutic milieus at adolescent residential treatment centers are usually characterized by the following elements: consistent rules and routines, program activities, group sessions, individual psychotherapy, conflict interventions, incentive systems, special education, family treatment, parent education groups, and individual behavior modification programs (Whittaker, 1979). More specifically, certain treatments have been advocated for certain problems. For the large proportion of depressed adolescents in residential treatment, Francis & Hart (1992) recommend social skills training, cognitive therapy, and a general increase in activity. For antisocial adolescents, behavioral management and social skills training is effective (Lochman et al., 1992) and anger control programs have a demonstrated success (Feindler et al., 1986). Traditional substance abuse treatments are effective when modified to the background of a particular patient and to the particular abused substance (Kaminer & Bukstein, 1992). Cognitive behavior therapy has been very successful in residential treatments, especially when booster sessions are given after the adolescent is re-exposed to the real world and when the treatment is modified to be age-specific (Kaminer & Bukstein, 1992). Behavior modification techniques of contingency management and token economies are often effective, as many of the children in treatment facilities were never exposed to consistent and adequate systems of discipline at home (Kolko, 1992). An increase in structure that is recognized as fair and predictable motivates young people to pursue rewards and fear negative consequences (Kolko, 1992). Many of these treatment modalities are implemented concurrently within an individual, and in those cases, research is unable to demonstrate which methods are most greatly contributing to treatment success (Kolko, 1992). Most treatment centers also involve an educational component. In 1975, all students who were labeled as emotionally disturbed were guaranteed a free, appropriate, and public education under law (Loar, 1992). Even in private facilities, the classroom can become an additional environment in which to evaluate and modify a child’s behavior, and teachers can contribute to the planning and implementing of the child’s treatment. Limitations of Residential Treatment Centers There are additional concerns specific to residential treatment centers. Children may become dependent on treatment centers for their structure (Barker, 1998) or for their support (Francis & Hart, 1992). Adolescents may encounter some unintended or unwanted effects (Green & Newman, 1996) such as learning more dysfunctional behaviors modeled by their dysfunctional peers (Barker, 1988). Children may feel disconnected from their families, and the successful treatment of the entire family system may be difficult to accomplish while the family unit is physically divided. Treatment can be very expensive and the length of treatment may be prematurely terminated for Colgate University Journal of the Sciences 157 financial reasons despite the clinician’s recommendation (Francis & Hart, 1992). This can create a phenomenon termed by Jemerin & Philips (1998) as the “Hello-Goodbye Cycle” that describes the rapid revolving door of patients going in and out of treatment. Such a cycle disappoints and exhausts the staff, weakens peer relationships, and creates an environment with more frequent displays of serious maladaptive behaviors. In addition, patients who seek admittance to a residential treatment program are often found retelling their stories again, going through diagnostic evaluations again, and filling out administrative paper work again, as this intake is not often the first intervention attempt (Kolko, 1992). Multiple intakes also imply multiple failures, and patients usually arrive at residential treatment centers frustrated, hopeless, or otherwise negatively disposed. I believe there are two problems in residential treatment for adolescents that overshadow the others. The first is that child behavior is extremely context dependent (Barker, 1988). For example, the Ontario Child Health Study (Boyle et al., 1987) showed little overlap between disturbed behavior at school and at home, implying that generalizing behaviors learned at a residential facility may be difficult. Restrictive environments that do not allow adolescents the freedom to experiment with their new skills prevent the observation and modification of the most problematic behaviors (Kolko, 1992). Many times adolescents will make major improvements during the residential treatment that are lost almost immediately after discharge. As Leichman & Leichman (2001, p.22) relate, “All too often they [clinicians] witness the youngsters who blossom in the safe, structured, and nurturant milieus provided in the best residential facilities flounder when transplanted into the radically different environments of their home communities.” This phenomenon may be due in part to the attempt of many treatment centers to complete symptom reduction before beginning the development of positive adaptability. When time runs out, this under prioritized aspect of change may remain neglected (Pratt & Moreland, 1996). The second major problem of current residential treatment is, for reasons like the one described above, there is doubt as to whether the end result of residential therapeutic treatment for adolescents is actually successful (Barker, 1988). Treatment Outcome Studies The question of successful outcome is not new to the field of residential treatment. Early outcome studies in residential treatment documented complete failures (Shamsie, 1981) and classic studies such as the one conducted at the Menninger Clinic’s Children’s Hospital often included schizophrenics and psychotics within their samples (Levy, 1969) that are now treated at separate facilities. With reforms in the methodology of psychotherapy, and in the measures used to define successful outcome, recent studies have shown moderately successful results. In 1991, Curry found that 60%-80% of young people have improved functioning at the time of follow-up as compared to the time of treatment commencement. A meta-analysis by Weisz et al. (1992) demonstrated that treated adolescents do better than 76%-81% of non-treated students in controlled studies of outpatient therapies. Pfeiffer (1989) and Pfeiffer & Strzelecki (1990) reached similar conclusions in their reviews of inpatient populations that spanned from 1975-1990. Blackman, Eustace, & Chaudhury (1991) published a 1-3 year follow-up of adolescents who completed residential treatment stating that severe impairment of global functioning Colgate University Journal of the Sciences 158 at admission was elevated to moderate impairment at discharge, and to the normal range at follow-up. The overarching goal of such research is to ensure that we are helping our suffering adolescents in the best way possible (Pratt & Moreland, 1996). Beyond the determination of program success, this research can also improve treatment components, generate reports to funding sources and accrediting bodies, help place children with specific pathologies into appropriate placements (Curry, 1995), demonstrate success to clients and third party payers (Zimmerman, 1998), and potentially influence public policy (Pratt & Moreland, 1996). Eysenck’s (1994) claim that only professional psychologists have a vested interested in such research in order to maintain their livelihood has been dismissed. As useful as this research has the potential to be, it has lagged behind in development for all too long (Zimmerman & Sanders, 1988), and is currently in an unsatisfactory state. Zimmerman & Sanders (1998) speculate that the lack of current literature stems from the lack of residential treatment centers for adolescents before 1960 and from the difficulty in tracking the young and transient participants for follow-up studies. It is particularly hard to study adolescent residential facilities because the populations at individual institutions are so small and the programs across institutions are so distinguished (Burks, 1995). Curry (1995) discovered the following startling statistics regarding the prevalence of research at residential treatment centers. Few practicing psychologists in contemporary residential settings engage in applied research, only 11% of them considering it part of their job. Only 64% of facilities engage in any type of research at all. Of the research being done at treatment centers, 85% are quality assurance tests, 65% outcome research, and 50% satisfaction research. 34% of the facilities engaged in applied research admit that such studies are externally mandated. 76% of centers have a job position dedicated to research, but only 25% have a budget for such research. When data is collected, only 58% of programs use it for improvement, only 25% to evaluate effectiveness, only 16% to assure quality, and only 14% for aftercare planning. Even fewer reported using the data for the purpose of marketing, scientific publication, generating reports to funders, and for client selection. Only 69% of facilities actually quantify the results of their data collection. Curry (1995) also reported that the most common method residential treatment centers use to collect data is mailed questionnaires (47%), followed by phone interviews (37%). Response rates via mail are usually 60%, and by phone usually 74%. The four most commonly outcomes investigated are the state of familial relations, legal involvement, school attendance, and emotional well-being. Other common measures include: need for further treatment, completion of aftercare, living status, decrease in symptomology, type of education obtained, completion of treatment goals, and stability of placement after discharge. Research methods are generally constrained by inadequate resources and inherent methodological difficulties. For example, only 14% of residential outcome studies use any type of contrast group. Actual control groups are nearly impossible since there are no groups of people that are similar in level of functioning, severity of symptoms, family histories, and socio-economics, that would not create a legal and ethical dilemma if they were not given treatment for as long as treatment and follow-up studies take (Weisz et al, 1992). Seventy-five percent of treatment facilities do Colgate University Journal of the Sciences 159 not collect pretreatment evaluations that could be used to create baseline measures (Pfeiffer, 1989) as an alternative form of control. As Zimmerman (1998, p.46) said, the “need for improving outcome evaluation in residential treatment programs cannot be overstated.” Research methods in the field have already been continuously improving. Originally, the only valued measure of outcome was whether the adolescent could return to living with the family, ignoring the tendency of families to mask certain problems, adjust to accommodate problems, or to outright tolerate many problems. Research has since shifted to looking for ways a recovering patient has developed his or her own positive and individual identity (Zimmerman et al., 2001). Research has also shifted to the use of standardized questionnaires, collected well after discharge, with more than one follow-up, and has attempted to contact every member of the population, trying to compare them to a genuine contrast group (Zimmerman, 1998). Good studies are expected to use multiple measures of outcome (Green & Newman, 1996), though as many as 68% of outcomes studies use assessments by only one person (Pfeiffer, 1989). Even among clinical staff, inter-rater reliability of outcome rating may be as low as .42 (Mordock, 1986), making multiple impressions essential. Based on the research that has been collected and analyzed, several reports have been published with recommendations as to how to improve residential treatment. Pfeiffer & Strzelecki (1990) advocate shorter treatments for a smoother transition back into the natural community, and Barker (1988) believes that treatment over six months should be avoided at all costs. Ney et al. (1988) do not think it matters how long the treatment lasts, so long as the length of time is clearly specified at the time of admission. Barker (1988) insists that a discharge plan should be in place at the time of admission, that the family should be involved in treatment, that the goals of the treatment plan should be clearly defined, and that the young person should spend as much time in the physical custody of the parents during treatment as possible. Some of these recommendations are highly contested because the suggestions are unsubstantiated by research or because the research was conducted without meaningful levels of external validity. Clinicians and researchers do agree that of utmost importance is the need for the maintenance of gains that are made in treatment facilities. Leichtman & Leichtman (2001) argue that this can be achieved by continuing treatment on an outpatient level. Currey (1995) found that post-discharge support is a strong predictor of later adjustment. Burks’ (1995) study of the Edgewood Children’s Center discovered that consistent family therapy post-treatment correlated with positive outcome, but that sporadic counseling had no effect. She also believes that discharge to a family unit is better than discharge to any institution. Additionally, it is speculated that students need to be given opportunities to act out in gradually less restrictive and supervised residential environments in order to have a greater potential for their learning to be generalized to the real world. Maluccio & Marlow (1972) suggest participation of residents in community programs in order to foster these goals. Colgate University Journal of the Sciences 160 Two Styles of Outcome Research: The Efficacy vs. Effectiveness Debate In order to make any further recommendations to the clinicians at treatment centers, more conclusive research must be done. There are two types of outcome studies in clinical psychology that can contribute to this knowledge base: efficacy studies and effectives studies. Efficacy studies have high levels of internal validity. Many are random controlled trials with a fixed duration of therapy, the inability of therapists to switch methodology in the midst of treatment in a self-correcting fashion, the exclusion of the co-morbidity and sub-clinical diagnoses common in the field, and the avoidance of subject self-selection into specific treatment modalities (Seligman, 1995). Therapists get special training in treatment methodology and subjects are volunteers (Pratt & Moreland, 1996). Efficacy studies do not evaluate treatment as it is actually performed in community settings, and thus the findings are sometimes less meaningful to those who conduct actual clinical practice (Goldfried & Wolfe, 1998). Efficacy studies may also maximize the differences found between treatment and placebo effects. By the definition of placebo, the administrators of the placebo treatment do not usually believe that it will have therapeutic effects (Eysenck, 1994), thus negating its power. A rigid scientific outlook often overlooks the subjective effects of treatment, such as increased morale, and the meaning of clinically significant results. (Pratt & Moreland, 1996). It is very easy to become so focused on the research paradigm that one ignores ecological significance (Goldfried & Wolfe, 1998). Therapy research adopted these methods in the 1980s in order to compete with pharmaceutical companies. This standard of control was set by the National Institute of Mental Health, which is a major source of funding, when it declared that clinical studies must study populations with particular DSM-IV diagnoses in order to receive grants (Goldfried & Wolfe, 1998). This facilitates communication within the field, but also eliminates half of all adolescents from studies because they have co-morbid disorders (Pratt & Moreland, 1996). This is even more problematic for adolescents because some typical problems (such as substance abuse) do not have explicit diagnostic criteria in the DSM for their age group (Kaminer & Bukstein, 1992). Residential treatment is particularly sensitive to the many difficulties of implementing controlled studies since it is very hard to prevent treatment effects from affecting the control groups in the close living quarters of a single facility, and it is also very difficult to attribute significant outcome to manipulated variables across different treatment settings (Curry, 1995). On the other hand, effectiveness studies are studies of treatment applied in more typical community settings. These studies lack some of the internal controls that are consistent with good scientific practice, but have certain advantages in external validity that make them very valuable to practitioners. Such studies can integrate established efficacy with the practicality, popularity, and cost-effectiveness of treatment (Jacobson & Christensen, 1996). Effectiveness studies allow patients to stop treatment as they would in the natural world based on feelings of improvement, feelings of no improvement, or shortages in funding. In the field, there are no strict research manuals helping therapists by outlining treatment protocols, which are often accused of being at the expense of the therapeutic alliance anyway (Goldfried & Wolfe, 1998). Therapist resistance to new models and to program adjustments is another variable encountered in the field that is almost never found in the lab (Wong, 1999). A number of these effectiveness studies have been completed to evaluate residential treatment. When these studies were Colgate University Journal of the Sciences 161 reviewed together by Weisz et al. (1992), they found no different between completers and dropouts one year later. However, the studies included in this survey were older ones, so it is not clear if a meta-analysis on newer studies would produce similar disappointing results. Consumer Reports: A Model for Effectiveness The now well-known Consumer Reports (CR) study, designed by Seligman (1995), is an example of an effectiveness study that has had a pervasive impact on the field. The study asked magazine readers whether they had used psychotherapy within the previous three years, whether the specific problem that they sought treatment for was helped, if patients were generally satisfied with treatment, and if they sensed any global improvement in their functioning. With merely a 13% response rate, Seligman concluded amongst other things that: treatment by mental health professionals works, that long term therapy is better than short term therapy, that people who actively pick their therapy and therapist do better in treatment than people who are passive recipients of such decisions, and that clients with limited insurance coverage have poorer outcome. These findings point out several shortcomings of efficacy studies while encouraging the continued development of long-term psychotherapies. At least for early stage treatment evaluations, it is easy to find merit in his advocacy of effectiveness studies. Future effectiveness studies should, however, make some methodical adjustments to this research model that will allow for greater internal validity. It must be recognized that some “passive recipients” of treatment may not do the “active shopping” for a particular therapist themselves, but may have other people do a thorough search for them with their best interest in mind. If Seligman’s paradigm is to be extended to children, I suspect that this new category will become quite important. In future studies all subjects should be treatment completers, and a more detailed analysis of areas of problems and successes should be documented. Seligman acknowledged his need for more details, but felt that the survey would have been too cumbersome. In order to use a lengthy survey without harming the potential response rate, experimenters will have to look for a very unique population or plan for a substantial incentive to participate. Most importantly, an effectiveness study will benefit from using multiple measures instead of simply a selfreport from the individual in therapy. More than one person’s opinion of the patient’s change will make the findings much more meaningful, especially if one evaluation can be blindly objective. A diagnostic tool with standardized norms could also be included in the survey materials in order to objectively measure the patient’s return to a non-clinical state. The Academy at Swift River Residential Treatment Facility The present study involves the study of the effectiveness of a relatively unique residential treatment program, the Academy at Swift River (ASR). ASR is a treatment facility in Western Massachusetts that refers to itself as an emotional growth boarding school for college-bound adolescents. The program is unique in many ways in its attempts to resolve some of the problems currently pervading adolescent residential treatment, making it a very worthy candidate for outcome study. The 630-acre campus has the capacity to serve 130 students, and like most other facilities, is currently serving more than that number. There are on average 80 male students and 30 female students Colgate University Journal of the Sciences 162 using campus beds at any given time, and many others traveling off campus. Treatment is broken up into three large phases: a wilderness experience known as base camp, a twelve month stay on the main campus with academic classes and group therapy sessions, and a Costa Rica service learning project. Tuition for this intensive therapeutic environment is $5,600 a month, with extra costs associated with the wilderness and Costa Rica components, and a $1500 extra charge if the child is on medication and needs to be monitored by a psychiatrist (retrieved from: http://www.swiftriver.com). As is the case at other residential treatment facilities, the desperate parents of these students feel that they cannot help their children on their own, and are often frustrated with years of failed treatment trials with professionals. The students are slightly older than the mean across outcome studies, ranging from 13-17 at admission. The common diagnoses are similar at Swift River to those at other residential facilities for adolescents, with the exception that the academy does not typically accept students with psychotic disorders or with intelligence scores in the mentally retarded range that could prevent success in their academic program. As with other residential centers, the proportion of adopted children at Swift River is 30% (Blackman et al., 1991). The program takes approximately 14 months to complete with up to 1 month of variability dependent on how long the base-camp transition takes. This program is a longer program that those advised by several experts in the field. ASR provides an accredited high school education on the grounds in addition to 24-hour crisis intervention services and behavioral observation. Actual treatment is truly integrative and includes the common models of cognitive-behavioral therapy, experiential therapy, psycho-education, behavioral modification, social skill building, dialectical/emotional therapy, family therapy, interpersonal therapy, group therapy, and substance abuse treatment groups. The treatment is extremely family-focused, but letters and weekly phone conversations are used to foster positive communication rather than frequently placing the student back home. In fact, ASR only plans for four parent visitations over the entire treatment. The academy attempts to teach adaptive traits while simultaneously reducing symptoms instead of performing these tasks sequentially. Unlike other treatment facilities that have been studied, ASR has outlined their treatment goals and methods for each particular phase of therapy. Perhaps the strongest distinction of this program is in its attempt to reflect the recommendations of treatment literature that advises that (1) large amounts of planning go into aftercare (including placement selection and improved family relations) and (2) students are gradually given real world freedoms to test their new skills before discharge. The largest drawback of the facility is the lack of any prior self-reflective research, aside from the gathering of anecdotal accounts, and the lack of any standardized intake measures to serve as a baseline for outcome evaluations to begin. Because there is a large deficit of well-designed outcome studies on the treatment of inpatient adolescents with applications for the real world (Lockman et al., 1992), and because the typical demands of clinical care conflict with the resources needed for research, Curry (1995) suggested that residential treatment centers coordinate with colleges whenever possible to do competent outcome research. The present study examines the outcome of ASR graduates in the dimensions of psychopathology (e.g., depression, conduct problems, anxiety), positive adaptation (e.g., academic achievement, relationships, involvement in activities), and consumer satisfaction. The data reflect the Colgate University Journal of the Sciences 163 students’ current well-being, gathered through student self-report and parental report. Students and parents both completed a detailed questionnaire regarding their perceptions of student change during treatment and a standardized questionnaire with national norms used to assess whether the student has returned to a non-clinical status. My predictions were that (1) participants would report decreases in levels of psychopathology, given that the pre-treatment behaviors were so extreme, but that many of the students would still remain in the clinical range, (2) participants would report levels of positive adaptations to have changed relatively less from pre-treatment to post-treatment, as these changes were not as salient, but many of the students would have returned to the normal range due to ASR’s unique focus on personal growth, and (3) participants would report high levels of satisfaction because predictions one and two predict a net positive outcome in the eyes of the patients and their parents.