Multifunctional Treatment in Residential and Community Settings
This Residential Treatment Project is the result of a comprehensive review of the research on residential treatment of antisocial behaviour in youth. This review was initiated by The Behavioural Centre and sponsored by The Ministry of Family Affairs in Norway (BFD), The National Board of Institutional Care (SiS) and Centre for Evaluation of Social Services (CUS) in Sweden. The review was published in Norwegian and Swedish in 2003.
The project includes several steps where the review of the research was the first step.
The next step was to develop a treatment program in residential settings based on the conclusions from the review of the research. This work is also made in cooperation between the two countries. The treatment program or treatment model is described in manuals, and is named “MultifunC” – “Multifunctional Treatment in Residential and Community Settings”.
The third step was to implement the new treatment program into praxis in Norway and in Sweden. In Norway the program is implemented in five new units and in Sweden in two units. The first units were established in 2005, and the last ones in 2007. In addition Denmark implemented their first MultifunC unit during 2011, and the next during 2012. Today there are nine units in Norway, Sweden and Denmark. The units are small facilities (8 juveniles in each) and are close connected to society with no fences or closed doors.
The fourth step is to evaluate the treatment program. There will be one study of the quality of program implementing. In this study the Correctional Program Assessment Inventory (CPAI) is used. The implementation studies are finished in Norway and in Sweden. In addition there are ongoing a study of the effects of the program. This is performed as a matched control group study and was started during 2010 both in Norway and in Sweden. The results for the first year follow up will be ready in Sweden during 2013.
In Norway about 220 juveniles have been treated in MutifunC institutions so far (2012). There have been about 22% placement breakdown during residential stay and about 12% breakdown during the integrated aftercare. That means that about 70 % have completed the whole treatment program, included the aftercare integrated in the program. Preliminary follow up of the juveniles indicates a success rate of about 60 to 70 % measured by the absence of re-offending behaviour, a positively change in school or work and family function, and no further placements.
This paper consists of two parts. The first gives a short description of the conclusions from the research which is the basis for the program. The second part gives a short description of the treatment program MultifunC.
REVIEW OF THE RESEARCH
Residential treatment of antisocial behaviour (Andreassen, 2003)
Residential treatments have been the most commonly used treatment intervention for antisocial behaviour in youth within Norway and Sweden. Unfortunately there have been no systematic research of the effects, and there have been few guidelines from research. This has led to large variations in treatment and to the fact that great deals of the treatment interventions have been based on beliefs of effects and ideologies more than on facts.
Treatment of antisocial behaviour in youth is known to be difficult. For years the ”nothing works” vs. ”what works” debate has been going on. An expert conference in Norway in 1997 concluded that home-based interventions are more effective than treatment in residential settings, and that research gives no guidelines for residential treatment. As a result The Norwegian Center for Studies of Conduct Problems and Innovative Practice (The Behavioural Centre) has been established with the aim to implement and evaluate evidence based methods in the prevention and treatment of serious behaviour problems in children and youth. Since 1999, Parent Management Training (Oregon model) (Patterson, 1982; Forgatch, 1994) and Multisystemic therapy (Henggeler et al., 1998) have been implemented in most of Norway.
Later a review of the research on residential treatment concluded that research in fact gives guidelines for effective residential treatment of antisocial behaviour in youth (Andreassen, 2003). Even if there is an agreement that home-based treatment gives the best effects, residential treatment may give relatively large positive effects on behaviour (Lösel, 1993).
One important conclusion was that residential interventions are not equally effective. Some gives no or negative effects. The research reveals important factors that discriminate between effective and ineffective residential treatment. Another important conclusion is that no single treatment approach alone is enough to change antisocial behaviour. Treatment approach is only one of several factors contributing to positive outcomes. Based on the research several important topics may be identified. Most conclusions on effective treatment approaches and principles are based on meta-analyses of mostly controlled studies, while conclusions in the other areas more often are based on correlation studies and less controlled studies.
Principles of effective residential treatment
Perhaps the most important results from the research is the formulation of “The Principles of Effective Treatment”, developed by Andrews, Zinger, Hoge, Bonta, Gendreau and Cullen in 1990, which is later supported by several meta-analyses in the years after. The principles imply that effective treatment in residential settings as well as in open settings follows the three principles of risk, need and responsivity.
The risk principle:
This principle states that intensive treatment gives best effects for medium to high-risk youth, and little or no effect for low risk youth. Interventions like Residential treatment should therefore focus on medium to high-risk youth. High risk youth are youth that have many risk factors supporting antisocial behaviour.
The need principle:
This principle states that the targets of interventions should be known risk factors for antisocial behaviour. Not all risk factors are modifiable. Those that are open to change (dynamic) are called ”criminogenic needs” and are seen as promising targets for intervention. Changes in these are associated with changes in antisocial behaviour.
Criminogenic needs (or risk factors) are characteristics of the individual youth, but also of the ecology of the youth; the family, peers, school and neighbourhood. Individual “criminogenic” needs include: (1) “antisocial/procriminal attitudes, values, beliefs and cognitive-emotional states (that is, personal cognitive supports for crime)”; (2) “procriminal associates and isolation from anticriminal peers (that is, interpersonal supports for crime)”; and (3) antisocial personality factors, such as impulsiveness, risk-taking, and lack of self-control (Andrews 1995; Andrews and Bonta, 1998; 2010 and Gendreau, Little, and Goggin 1996).
In the family, the identified “criminogenic” needs or risk factors are targeted in Multisystemic Therapy (MST). Moreover, the association with antisocial friends and lack of contact with prosocial friends is seen as promising target for change. Conversely, the research suggests that many factors thought to cause crime, such as low self-esteem, are unrelated or only weakly related to recidivism. Thus, targeting these factors for intervention will produce little, if any, change in serious antisocial behaviour.
A summary of important and less important targets of change is found in Andrews and Bonta (1998; 2010). The main message is that the promising targets of change are directly associated with antisocial behaviour, and that the treatment should also focus on several factors outside the youth like the family, the friends, and school.
The responsivity principle:
This principle states that the treatment should be matched to the learning style of the antisocial youth. Further, general responsivity is differentiated from specific responsivity.
General responsivity implies that cognitive behaviour approach is the most effective treatment approach for antisocial youth as a group, especially if several methods within the approach are used (multimodal). This approach is well designed to teach the youth critical social skills, to replace antisocial with prosocial feelings and thoughts, and to train aggression control. Several treatment models or programs based on cognitive behaviour approach have been developed; Aggression Replacement Training (ART), and EQUIP. The effectiveness of cognitive behaviour approaches is supported of several metaanalysis (Garrett, 1985; Lipsey, 1992, 1999; Izzo and Ross, 1990; Redondo et al, 1997/99; Dowden and Andrews, 2000). In addition to these methods token-economy (contingency management) is often used with good results.
Specific responsivity refers to matching styles and modes of treatment service to the learning
style of individual offenders (Andrews and Bonta, 1998; Gendreau 1996). Factors that might be taken into account in service delivery are the offenders’ lack of motivation to participate in the program, feelings of anxiety or depression, and neuropsychological deficits stemming from early childhood experiences (e.g., physical trauma).
Several metaanalysis supports the conclusion that interventions in line with these principles are more effective than others.
No treatment approach is effective if the actual practice is not in agreement with the underlying theoretical principles and intentions. Several studies have shown that programs that monitor the treatment integrity or fidelity produce better outcomes than those that do not (e.g. Henggeler et al, 1994). Treatment integrity might be secured through the use of systematic evaluation, and structured treatment manuals make it easier to implement the program as planned. Among institutions that use cognitive behaviour approach the best outcomes are found when several methods within the approach are available, and where multimodal models are used (e.g. Aggression Replacement Training, Equip). These models dispose treatment manuals. Hollin (1995) have identified important factors to secure integrity. Programs should be based on a specific treatment approach, there should be no major differences in opinions among staff about theories of antisocial behaviour and treatment, the staff should be systematically trained in the agreed upon methods, and treatment should be evaluated, etc.
The peer culture:
In addition to the implementation of “principles of effective treatment” and the cognitive behaviour treatment approaches, effective residential treatments should take other important risk factors into consideration. One of these is the influence of antisocial peers and the antisocial youth culture. When a youth is placed in a residential setting (or any other group setting) together with other antisocial youths, an unintended consequence might be that the group might contribute to the development and maintenance of antisocial behaviour (Dishion et al, 1999). This is perhaps the most important explanation of the weak effects of residential treatment. Homogenous group treatment increases the risk of reinforcement of deviant values, peers who models antisocial behaviour and values and stronger identification with a delinquent subculture (Arnold & Hughes, 1999). The staff should be able to moderate the influence on this negative culture, if treatment should be successful.
The three main risk factors that seem to influence the youth culture are; Isolation from society, too much control and too little autonomy, and lack of common treatment beliefs and practice among staff. It seems important to establish contact between the antisocial youth and prosocial youth during the treatment process. It is also important to strike a good balance between youth autonomy/support and staff control (Scholte and Van der Ploeg, 2000). Both too little and too much autonomy might influence the behaviour in a negative direction. A staff who functions as a team, are in a better position to change the culture in positive direction than a fragmented staff (Bullock et al., 1998).
Management of violent behaviour:
Research shows that a large part of youths with antisocial behaviour never fulfil their stay in residential settings. About 30-50 % of youth in residential treatment end the treatment earlier than planned, and without finishing the treatment. The most common reasons for this are running away and violent behaviour. It is therefore of great importance that the staff are able to handle violent behaviour.
Staff with small or few conflicts and who share beliefs about treatment and agree about how the treatment should be done, are usually better at managing violent behaviour than those who do not. Important components are skills in how to avoid and prevent violent behaviour, as well as how to manage such behaviour.
Many of the youth return home after the stay in residential treatment. Ideally, the aftercare should be considered an integral and obligatory part of the treatment process. To have lasting effects the treatment processes have to include considerable and systematic help to establish a prosocial life at home. This is in accordance with the principle of need, and focus on the same risk factors (dynamic needs) inside as well as outside of the residential setting.
Even if the message from research gives guidelines for treatment, it has to be emphasised that treatment of antisocial behaviour is demanding, and that it is difficult to make an effective residential program last over time. Interventions outside residential setting – family- and community based treatment – should be preferred whenever possible. However, residential treatment plays an important role for those who are not eligible for home-based interventions, or for whom it does not work. There is also a need for more research on important topics in order to establish evidence-based practice in institutions. But even if research today have not found all the answers, important differences between effective and less effective interventions are pointed out.
Our knowledge about residential treatment in Nordic countries also makes it clear that to a large extent, practice is not in agreement with the messages from the research. In addition much of the findings on effective treatment are based on international studies. It is therefore important both to modify the existing residential treatment, and to examine if the principles of effective treatment work in the Nordic context. To do this, the messages from research have to be translated and implemented into practise. Based on the findings from the research the following recommendations are made as a model for residential treatment:
- · The residential treatment should target medium to high-risk offenders. This implies that the risk level of the youth should be assessed.
- · The targets of the interventions should be known dynamic risk factors for change. This means that there has to be an assessment of the criminogenic needs. Since the risk factors are found both within the individual youth and in his or her ecology, the focus for change must be on all areas. In addition to changing the youth’s behaviour, the treatment has to focus on changing dynamic risk factors within the family, the peer relations, and the youth’s function at school.
- · The residential treatment should use cognitive behavioural methods for changing the youth’s behaviour and to help him/her to develop appropriate competence (control of aggression, social skills, and moral development). In carrying out the treatment, there should be a focus on individual differences. This means that responsivity factors should be assessed. The staffs need good knowledge about the methods, systematic training in putting them into practice and develop agreement on how the methods are been used. One example of promising models based on cognitive behaviour approach is Aggression Replacement Training (ART).
- · The treatment climate has to be balanced between autonomy/support and control (firm but fair). There has to be clear statements about which areas the staffs have to control, and which the youth may have influence on. The youths should be treated with respect and emotional support.
- · The staffs need competence in how to prevent and manage violent behaviour in a constructive way.
- · There has to be systems to monitor the treatment integrity/fidelity.
- · There has to be an aftercare integrated into the treatment process, with focus on the criminogenic needs.
To make this possibly, the staffs should have training both in what the research tell about development of antisocial behaviour (the importance of risk-factors), and in important treatment principles. This includes training in methods based on cognitive behaviour approach (ART), etc.
Based on the research the treatment that takes place in residential setting is only a part of the total treatment process. The aftercare is equally important. In addition the risk for negative influence from antisocial peers implies that the period of time used in a residential setting should be as short as possibly. The goal of the treatment in residential setting alone should not be to complete the treatment or to reach complete treatment outcomes (changes in antisocial behaviour and changes of the dynamic risk factors), but to make the youth able to profit from home-based treatment interventions by helping the youth to develop necessary skills and sufficient changes in behaviour. The process of changing the dynamic risk factors should take place both during the residential treatment and a certain period after the youth has moved from this setting. Assessments of outcomes should include behavioural changes and changes in dynamic risk factors.
It is not sufficient to know what works or to describe an effective treatment program. There also have to be systems to monitor treatment integrity/fidelity to ensure that the youths and their family really get the interventions as planned.
Multifunctional Treatment in Residential and Community Settings
MultifunC is a treatment program for youth with serious behavioural difficulties (antisocial behaviour). The program is a result of a Norwegian-Swedish cooperation project which includes a review of the research.
The target group for MultifunC is juveniles with serious behavioural difficulties, high risk level, and who do not profit from home based interventions (MST).
The program builds on social ecological system theory, empirical research on causes to behavioural problems (correlates), systemic family therapy and cognitive behavioural modification. Important basis for the program is the understanding of behavioural problems as a result of risk factors within the youth and his/her ecology. The interventions focus on the known risk factors in all areas (youth, family, relations to peers, and school).
Organization of MultifunC
The program consists of a time-limited period in residential setting followed by a focused aftercare integrated in the program. Total intervention period for single youths will be assessed individually, but is usually about 10-12 months included aftercare. The youth stays in residential setting for about 6 months. Planning of targets for treatment during the residential stay and for the intervention as a whole is done at intake in cooperation with the youth and his/her family. Ending the residential stay and the intervention as a whole is based on concrete assessment of treatment success. The program is established as open units in association with the community. There will be made efforts to seek cooperation with schools in the community and to establish contact with prosocial peers in the local community.
During the residential stay there is a focus on changing the behaviour, training in social skills, and changing the attitudes regarding drugs, criminal behaviour, etc. Methods are structured and based on cognitive behavioural theory and social learning theory.
There will be made efforts to develop a treatment milieu with balance between control and autonomy where the staff controls negative behaviour in combination with involvement of the youth in decisions and planning.
During the whole intervention (residential treatment and aftercare) there will be a focus on changing the youths function in school settings, decrease in contact with antisocial peers, increase in contact with prosocial peers outside the institution, and support to the family as parents. The parents are involved in treatment planning and are supported based on principles from MST and PMT.
The treatment program
MultifunC is based on certain principles that include several topics of the treatment. Important principles are:
- · Serious behaviour problems are best helped by a focus on changing characteristics by the youth and the ecology of the youth which are directly related to the behaviour (criminogenic needs). The interventions focus on the youth, the family, the school and the peers. The treatment targets within each topic are defined based on their relation to the problem behaviour.
- · To succeed in lasting changes in community it is not sufficient to treat the youth in residential setting. Generalization of the skills and changes in behaviour to the community depends on supporting the youth and the family in natural community settings. MultifunC therefore includes a time limited period in residential setting followed by an integrated aftercare with focus on the criminogenic needs.
- · Effective conditions for changes include the involvement of the youth and his/her family in the treatment planning and process, and that the treatment process is made predictable to the involved parts. The youth and his/her family are informed about results from assessment, are involved in treatment planning, and have access to information about the development during the intervention. Rules and expectations are concrete and the youth is involved in all decisions regarding him/her self. Already at intake the aftercare is planned.
- · Serious behaviour problems, violent behaviour and threats are best reduced if the behaviour is met consistent from the staff and in conditions where negative behaviour does not result in rewards for the youth. MultifunC seeks through staff training to avoid violent behaviour from the youth, and to manage such behaviour in an effective way.
- · MultifunC acknowledges that the most important source of influence for youth is other youths. Even if it is important that the staff is consistent in their behaviour and is good role models, the youth will be more influenced by other youths. A placement in residential setting includes the risk of a negative influence from peers with antisocial behaviour. To establish contact with prosocial youths therefore is important. The youths should preferable go to an ordinary school in the community, and use leisure activities in the community. The aim of this focus is not to establish lasting relations, but to establish possibilities to prosocial influence.
Assessment and treatment planning
MultifunC includes its own assessment team with high competency. The team assesses the needs related to the behaviour problems for each single youth and his/her family. Assessment includes decision of target group. Assessment of target group is performed before placement in institution. Assessment of treatment targets is performed after placement.
The youths function and behaviour in the community is the basis for assessment and for development of treatment targets and plans. The aim of the intervention is to change the behaviour in community settings, and treatment targets (criminogenic needs) are related to this. Other targets/needs which develops during the intervention, and which partly may be a result of the placement in institution, is focused on but not integrated in aims of the intervention.
Assessment is based on the risk factors. The main instrument for assessment is the Youth Level of Service/Case Management Inventory (YLS/CMI). YLS/CMI assesses the total level of risk including both the static and the dynamic risk factors. The total risk level is used to decide the target group, and the dynamic risk factors (criminogenic needs) are used to decide treatment targets.
Treatment plans for each single youth is established with a focus on the risk factors within each area; youth, family, peers and school.
MultifunC acknowledges that youth with serious behaviour problems, in the same way as other, are individuals. The youth have some commonalities, but are also different from each other. As far as such differences may influence on the responses to the interventions, these will be assessed and integrated in treatment plans. Possibly topics to assess are social skills, mental capacity, depression, anxiety, etc.
Assessment is based mostly on standardized instruments and includes no more assessment than necessary to plan the interventions.
The methods are based on different principles depending of target area. For motivating the youth to participate in treatment, to participate in activities (social skills training, school, daily routines, etc.), and for behavioural changes generally, principles from Motivational Interviewing are used. Principles from this approach are well suited to decrease opposition from the youth and to help them in making reflections on their on problems. The staffs are trained in this approach.
To change the behaviour, train the youth in social skills, aggression control, and changes in attitudes, methods based on social learning theory and cognitive behaviour theory are used. This implies that positive behaviour consistent is rewarded while negative behaviour not is rewarded. A system of contingency management is used in MultifunC.
Social skills training is performed during the daily communication and by systematic training based on Aggression Replacement Training (ART). This program focuses on social skills training, training in aggression control, and on moral discussions. The ART-program includes training manuals for performance. The staffs are trained in ART.
The parents are seen as important persons for the youths, and are involved in the treatment. MultifunC acknowledges that parents to youths with behavioural problems often are in need for changes in their parental skills and strategies to succeed in changing the youth. To support or change the parental skills MultifunC uses principles from Parental Management Therapy (PMT) and Multisystemic Therapy (MST). The parents are trained in how to communicate and control their youth in a supportive way. They also are trained and supported in how to establish functionally routines for cooperation with school, other parents, and how to control the youth’s activities outside their home (leisure time). MultifunC dispose a family apartment where the parents are trained before the youth returns home. The parents and the youth are supported through planning and support during leaves from the institution before the youth returns home.
Organization of the intervention
MultifunC acknowledges that a residential stay is not sufficient to succeed in lasting changes in community if the ecology of the youth still remains the same as before. Parts of the ecology (parental functions) may be changed in parallel to the residential stay for the youth. Other parts necessary have to be influenced after the youth returns home (relations to peers and school). When the youth returns home there also is a new and different situation for communication between the parents and the youth. MultifunC therefore includes a period in residential setting followed by support to the family after the youth returns home (aftercare).
MultifunC focus on the risk factors within all areas during the residential stay and during the aftercare. The focus is on the youth, the family, the relations to peers, and school or work.
Based on the fact that a large part of the treatment has to focus on criminogenic needs or risk factors in the ecology of the youth to succeed, the treatment process is conceptualised as a process in three stages.
Based on the different topics in MultifunC the intervention program is organized in different teams with different functions. MultifunC has one leader who is responsibly for the unit as a whole. In addition there is one Assessment team, one Treatment team, one Pedagogical team, and one Family- and aftercare team.
The assessment team is responsibly for the assessment of the target group and establishing the treatment targets based on the assessment, and for development of treatment plans for each youth. The team also is responsibly for guidance on the treatment plans to the other teams in MultifunC during the treatment process.
The treatment team is responsibly for the daily treatment of the youth in the residential setting. This includes daily treatment milieu, contingency management, ART-training, leisure activities, and so on.
The pedagogical team is responsibly for specific pedagogical assessment, support to each youth regarding educational development, and for support and cooperation with local school authorities.
The family- and aftercare team is responsibly for treatment and support to the parents during the youths stay in residential setting, and after the youth returns home (aftercare). This includes involvement of the parents in decisions, education and training of the parents, and support through contact and visits in the family’s homes.
Quality Assurance of MultifunC is done through the following systems:
- · Manuals for MultifunC
- · Training program for the staff
- · Monitoring the treatment integrity (Quality Assurance Team)
There exist manuals for MultifunC as a whole and for the different topics included in MultifunC.
The manuals include the following:
- · Manual for MultifunC included theoretical basis, organization and important principles
- · Manual for Assessment in MultifunC
- · Manual for Residential treatment in MultifunC
- · Manual for Pedagogical treatment in MultifunC
- · Manual for Family treatment and aftercare in MultifunC
- · Manual for Contingency Management in MultifunC
Performance of specific components in MultifunC are based on specific manuals and training programs within the different components:
- · Therapeutic Management of Violence
- · Motivational Interviewing
- · Aggression Replacement Training
The staffs are trained as a group in the principles in MultifunC and in the different components. Included in the training program are basic principles in PMT and MST. The training program also includes the theoretical basis for MultifunC, and it is expected that all staff are able to formulate the theoretical basis and the central principles in MultifunC.
In addition to the manuals and the training program the practical performance of MultifunC is assessed by a Quality assurance team. The Norwegian team is responsible for monitoring the treatment integrity of all the five Norwegian units included in MultifunC. This team is as important part of MultifunC as the other teams in the units. The team will assess and correct the units when the principles and manuals in MultifunC are broken. The team will control which interventions the youth and the families’ really receive, and the quality of this. The focus is both on the intervention as a whole, and on the single components included (assessment, treatment planning, involvement of youth and parents, ART-training, etc.). The aim of this team’s work is to ensure treatment integrity of MultifunC. The team also will be responsibly for further development of MultifunC in cooperation with other involved parts in the project.
For more information, please contact the program developer: Tore Andreassen