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How to Evaluate Quality in Treatment Organizations for Young People
– and what Factors Matters for a Positive Treatment Process
Hur utvärderas kvalitet inom behandlande institutioner
– och vilka faktorer spelar egentligen roll för att en ung vuxen ska påverkas positivt
under en institutionsvistelse?
Jürgen Degner
Örebro University/The School of Law, Psychology, Social Work
2015
SAMMANFATTNING
Barn och ungdomar utvecklas i de allra flesta fall i ett sammanhang bestående av positiva familje- och vänrelationer,
samt genom utvecklande prosociala aktiviteter (arbete, skola och fritid) – medan ungdomar som är placerade på
institution ofta haft en uppväxtmiljö präglad av kriminalitet, missbruk och/eller andra psykosociala svårigheter. Den
behandlande institutionens uppdrag är därför att fokusera på de olika livs-områden (en s.k. multimodal ansats) som
bidragit till ungdomens nuvarande problembelastning. Detta innebär egentligen att en placering på en ungdomsinstitution
handlar om att befinna sig i ett miniatyrsamhälle, där det är summan av prosociala interaktioner, specifik
metod/programverksamhet och andra aktiviteter, dygnet-runt (24/7) som avser att förändra ungdomen i positiv riktning.
Detta innebär samtidigt att det är stora problem att utvärdera vilka specifika, och ”evidensbaserade” metoder (t.ex.
kognitiv beteendeterapi [KBT], motiverande samtal [MI], aggression replacement traning [ART]) som egentligen har
effekt på individens utveckling. Trots detta så implementeras specifika behandlingsmetoder just med argumentationen att
de är evidenstestade i ett antal studier och metaanalyser – med bl.a. institutions- och/eller fängelsepopulationer (dock inte
ART inom kriminalvården). Syftet med studien är, med utgångspunkt i ett 24/7-baserat pilotprojekt inom Statens
institutionsstyrelse (SiS), att kartlägga vilka a) organisatoriska förutsättningar som finns för att en ungdom ska kunna
utvecklas positivt inom institutionsmiljön, b) vilka hinder och möjligheter som utkristalliseras inom ramen för den
verksamhet som bedrivs, och c) att utreda och diskutera vad som behöver beaktas för att designa en utvärdering av en
individ placerad i en komplex institutionsmiljö. Metoden har en multistrategisk ansats och data har insamlats genom
CPAI-intervjuer (n=8) med institutionsledning tre pilotinstitutioner (särskilda ungdomshem) inom SiS regi. The
Correctional Program Assessment Inventory 2000 (CPAI) är ett instrument för att kartlägga organisatoriska
förutsättningar, behandlingsinnehåll, ledarskaps- och personalkarakteristik, samt proportionen mellan icke-schemalagda
och schemalagd/-bundna aktiviteter. Vidare genomfördes, under ett år, 12 projektmöten på vardera institutionen med
mellan 10-15 nyckelpersonal (institutionsledning, hälso- och skolpersonal samt avdelningspersonal), samt avslutningsvis
användes en enkät för att erhålla delvis samma, och kompletterande, information från samtliga personal på institutionerna
(ledning och personal) (n=103). Resultatet visar att av veckans totalt 168 timmar (8/8/8x7) spenderas en mindre andel tid
i schemalagda/-bundna aktiviteter (inklusive specifik metod) i relation till övrig icke-schemalagda/-bundna aktiviteter –
och där både schemalagda/-bundna och icke-schemalagda/-bundna aktiviteter har en diffus, och rörande ickeschemalagda/-bundna aktiviteter mycket svag koppling, till en tydlig pedagogisk, teoretisk eller metodisk utgångspunkt.
Detta resultat får stora komplikationer för vilket värde vi kan tillskriva de evidensanspråk som uttalas för specifika
metoder – och vilka tillämpas inom ramen för en institutionell kontext. En holistisk och komplimenterande syn på hur
institutionsbehandling (samma grundvillkor finns inom kriminalvården) ska kunna utvärderas kommer att diskuteras på
seminariet.
Nyckelord: Utvärdering, ungdomar, institutionsvård och prosociala interaktioner och aktiviteter.
INTRODUCTION
Most young people have positive relations to family and friends – and participate in pro-social
activities (e.g. school, work and leisure time). In contrast, delinquent youths, placed in
residential treatment care, often have dysfunctional relations and negative life experiences in
these key areas. When treatment for adolescents are performed in an institution, it is important
to realize that the total amount time, around the clock, will have an impact on the young adult,
positive or negative, depending on how the placement is organized and which type of
treatment methods being offered. Another key objective of the placement is for the youth to
understand the importance of breaking a destructive psychosocial development, as well as
stimulating education, and to actively create visions, or goals, for a future profession. In sum,
this is a very difficult task and requires not only theoretical and pedagogical skills by staff,
but also a consistency in the staff group, active cooperation between different professionals
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within (e.g., management, ward staff, school/teachers at the facility, psychologists, health
professionals) and between institutions and the local community (e.g., social service agency,
employment office, outside facility leisure activities, practical placement programs) to be
successful (Ahonen, 2012; Andreassen, 2003; Gendreau & Andrews, 1994).
The aim with this paper is to explore the a) organizational prerequisites for a youth to
develop positively in an institutional environment, b) the obstacles and opportunities that exist
in this settings, and c) discussing what needs to be considered for designing an evaluation of
an individual placed in a complex institutional context.
The 24/7-project
The project includes three Swedish state run pilot-institutions (five treatment wards). The
Correctional Program Assessment Inventory 2000 (CPAI) was used to perform 8 interviews
with head of institution (n=3) and ward manager (n=5). CPAI 2000 is an instrument aiming to
evaluate the quality of treatment programs for criminal offenders and delinquent youth in
institutional care. CPAI contains 131 questions covering program demographics,
organizational
culture,
program
implementation/maintenance,
management/staff
characteristics, client risk/needs practice, program characteristics, core correctional
practice, interagency communication and evaluation. In addition, we performed more than 12
project-meetings at all three pilot-institutions, and administered a questionnaire to all staff
(n=103) in the participating wards. The questionnaire is composed of 7 main areas all of
which are related to fundamental treatment components, such as:
…theoretical foundation, 5 items (e.g. My work demands intimate knowledge about theoretical
foundations, to perform treatment; treatment method/methods used, 5 items (e.g. I have intimate
knowledge of the treatment methods, to perform treatment); therapeutic perspective, 19 items (e.g. In my
work I consider a total absence of drugs to be a prerequisite for a positive treatment outcome); daily
structure, 24 items (e.g. There are clear instructions about how I should perform my duties); information
flow, 4 items (e.g. I receive enough information about what is happening at my workplace); treatment
climate, 3 items e.g. (What is your opinion of the solidarity among colleagues?); and specific
fundamental treatment components, 9 items (e.g. I work actively to involve the young people’s families in
treatment). (Ahonen, 2012, p. 54)
Until the end of 2014, there has been 12 regular project-meetings conducted at each of the
three pilot institutions. Each meeting began with a partly pre-planned structure, which were
both based on the project's objectives and issues, research in the area, as well as guidelines for
project-implementation (see e.g. The National Board, 2012). The final content for the
respective meetings have been continuously modified on the basis of the discussions that
occurred during the previous meeting at each institution. Below are examples of issues
discussed.
Invent all staff-operated and non-staff-operated activities – including school, method, work, and leisure
time – available in each ward.
b) Which of these different activities have a clear pedagogical, theoretical and knowledge based (research)
platform – but delivered without a “verified” treatment-manual.
c) Which of these different activities have a clear pedagogical, theoretical and knowledge based (research)
platform – but delivered with a “verified” treatment-manual.
a)
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EVALUATING INSTITUTIONAL TREATMENT PROGRAMS
CHALLENGES
INDIVIDUAL AND INSTITUTIONAL
The pathway to psychosocial maturity
A young person is normally expected to receive a variety of skills, in a relatively few number
of years, before she or he will become a productive adult in a larger societal context. This
continues throughout life, but the individual maturity and the skills required for the upcoming
role as an adult is mainly concentrated from the late teens to early adult age. During late
adolescence young people are expected to generally adopt more mature roles and take on
more demanding responsibilities (see e.g. Bronfenbrenner, 1979; Larson, 2006). A central
part of this is the teenage years, when experiences, norms and values accumulated and are
internalized into their own action plans. To enable this transformation from adolescent to
adulthood requires a lot of coordination of resources and skills. Steinberg, Chung & Little
(2004) and Greenberger (1984) define the personal goal for this transition process, with the
concept of psychosocial maturity. This means that a continuous and gradual developmentchain takes place in three key psychosocial domains: mastery/self-control and competence,
interpersonal relationship and social functioning skills, and (self-definition and selfgovernance. To achieve a profound psychosocial maturation and function as independent and
productive adults in today's industrialized society, young adults need, according to Steinberg,
Chung, and Little (2004), walk through a series of developmental and tasks within each of
these three domains.
In terms of mastery/self-control and competence, adolescents are expected, at the end of
transformation period, to have developed the necessary knowledge (school) and skills
(expertise) needed to understand the purpose of being a part of the social production and
community welfare organizations. Thereby, developing oneself through leisure activities and
appreciate higher values, such as different forms of culture. In line with this, the young adult
is expected to have achieved a sufficient level of education and vocational training to be
employable in the labour force. When it comes to interpersonal relationships and social
functioning, young adults are expected to have conquered the social skills necessary to
interact with others, and to be able to establish and maintain close relationships (cf. Bowlby,
1988 and the internal working model). They are expected to be able to work in groups and
take responsibility for the common resources available in the community. Further, taken their
own self-awareness into account, they need to have developed a positive sense of their own
personal worth as individuals and acquire the competence to act in a responsible and moral
way. However, that it is initially done as a result of external control/monitoring of any
"adult", but will later on, as the young grow older, be progressed by youth’s own internal
motivation. They are also expected to be independent/autonomous in relation to others, and
have a good understanding of how to achieve meaningful personal goals – and also have an
internal motivation for positive personal growth (see Larson, 2000; Larson, 2006). Even
though it is not expected that these "abilities" are fully developed in the late teens, they need
to have made significant progress in each of these three mentioned domains before she or he
is ready for transition to the role of a responsible adult. This is of course complicated facts,
but it is obvious aspects that we expect from – and how life in general looks for – an ordinary
young human being. In sum, it is central that most activities offered at the institution must
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have a goal, as well as a therapeutic and pedagogical intent (and being progression-based) –
and be linked to relevant research on what correlates with an individual to achieve
psychosocial maturity and develop into responsible young adults.
Prerequisites for institutional treatment
When young people with severe psychosocial problems are placed in institutional treatment
centers, it is crucial that the treatment program is based on an ethical, evidence- and
knowledge-based platform. This basically means that the organization, leadership styles and
staff should be govern by theories and methods that are proven effective for the each client
group (young people or adults), and that components of the treatment program (e.g.
education, job training, and other pro-social activities), everyday, are designed to foster a
positive and long lasting psychosocial development. This requires skills from both
management and staff.
Within the "What Works" research tradition model (i.e., what works for different type of
clients), we can trace a number of basic principles who are fundamentals in order to define a
human change organization as evidence- and knowledge-driven. These principles are
suggested both nationally and internationally by treatment researchers (Ahonen, 2012;
Andrews, Bonta & Wormith, 2010; Latessa, Cullen & Gendreau, 2002; Gendreau, Smith &
French, 2006). These principles, and starting points, also follows quality indicators found in
both organization theory in general (e.g. Christensen, Lægreid, Roness, Røvik, 2005), as well
as in social work and institutional care, more specific (Carmichael, 2005; Hicks, Gibbs,
Weatherly & Byford, 2009). Below, these principles will be briefly presented (see Latessa,
Cullen & Gendreau, 2002; Gendreau, Smith & French, 2006 for further descriptions):
1) The first principle addresses the programs demographics and organizational
culture/structure. Where emphasis will be on ensuring that the organization has well-defined
objectives, and strategies to achieve those objectives. There must be flexibility and an
openness to the application of new ideas in the work, together with a reflexive ethical
approach. The organization will work to provide a good atmosphere and low staff turnover,
through good communications – both between staff group in general, and between
management and staff.
2) The second point is the program implementation, which means that the staff skills match
the treatment program provided. This particular is to ensure that program components is
implemented in the way it is supposed (program fidelity). This principles also suggest a
continuously making analysis to determine if, for example, current research have made new
conclusions about the effectiveness of the specific care provided.
3) The third point is about management strategies, which emphasizes the importance of
that leaders and staff have adequate training, experience and a professional approach. Central
is also a progressive leadership to enthuse staff to develop their job skills and work
competence.
4) The fourth principle means that staff need to identify and offer treatment components
that will target the clients’ specific risk and protective factors (i.e. criminogenic need such as
to change a destructive lifestyles, "pro-criminal' attitudes, negative patterns of social
interaction with other people, strategies to prevent violence, the perception of anti-social role
models etc.), and to the level of treatment intensity (i.e. if there is high risk of relapse). And
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reverse, if there is a low risk of relapse, the treatment offered should have low intensity
(preferably in open care). This also is defined as the risk-need-responsivity model (R-N-R)
(Andrews, Bonta & Wormith, 2010). These three concepts forms the backbone of what is
today termed as a prerequisite for successful treatment for clients with different types of
psychological and psychiatric conditions, as well as clients with comorbidity overlaps
(numerous symptoms including drug problems and criminality).
5) This principle is about that the specific methods and program offered in the institution
must contain components (preferably cognitive and social learning theory), showing evidence
in order to contribute to a positive treatment outcome (see for example Latessa, Cullen &
Gendreau, 2002). It means to specifically target the young peoples’ both dynamic risk and
protective factors.
6) The sixth principle is about how staff, in everyday situations, actually train the residents
in various problem solving techniques, stimulates their learning abilities and vocational skills
training, positive reinforcement for positive behavior, train the clients on alternative responses
to problematic situations, and increase the youngsters’ prosocial behaviors in increasingly
more difficult situations.
7) The seventh principle is about the importance of cooperation between the institution and
various agencies, such as social welfare office, psychiatric institutions, employment office,
other outpatient care, education agencies, and voluntary organizations.
8) The final principle involves a systematic evaluation of the treatment program at an
organizational level (which includes the quality, and performance, of all the principles), as
well as a systematic monitoring of the treatment progress for each client – throughout the
treatment process.
In sum, to understand the facility milieu, in which the staff operates, we need to have
advanced knowledge, from theory and research, in a number of key areas based on the
principles above: This means that staff not only must have a professional and allianceforming approach (see e.g. SiS, 2012; Ahonen, 2012), but the theoretical platform, for a 24/7treatment program, as indicated by the eight principles, must be multifaceted; with core
concepts emanating from both organizational and leadership theory (see e.g. Gendreau, Smith
& French, 2006). Further, it is essential to understand human development, based on
developmental ecology/-psychology, theory of motivation and moral development, just to
name a few (Ahonen, 2012; Steinberg, et al., 2004; Larsen, 2006; Bronfenbrenner, 1979). To
conclude, the ability to work knowledge/evidence-based treatment for both young people, and
adults, in treatment institutions (although the same factors, of course, can be transferred to
adult prisons and psychiatry outpatient organizations or similar measures) must be understood
in light of this complexity (see figure 1 below). This is also one the reasons why there is an
urgent need for discussing the concept of evidence based methods, and the possibility to
evaluate these treatment programs in this multifaceted milieu.
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Inside a treatment facility
Based on the project-meetings and CPAI-interviews in the 24/7-project, data show that the
young people/residents spend more time in non-scheduled/supervised activities (e.g. watching
TV, playing computer games, spending time with fellow-residents, sports), than in scheduled
staff-monitored and goal-oriented (e.g. school, vocational/work training programs, pro-social
skill training activities) programs. Both scheduled and non-scheduled activities have a diffuse
– or no connection at all – link to a pedagogical, theoretical or methodological viewpoint.
(See figure 2 below):
Figure 2. An approximate day schedule at the wards/institution:
Further, results from project meetings, interviews, and survey show that although the staffs
partly shares a common view on the theories and methods used in each department, there are
significant differences. This affects not only the staff’s common strategies and control of
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treatment content, but also the implementation of methods and approaches. When applying
the theories, methods and pro-social activities, there are both differences and similarities: In
two of the wards there are a social learning theoretical platform, with methods such as ART
(Aggression Replacement Training), ADL (Activities of daily living), and various forms of
therapeutic discussions and meetings with key staff (but rarely with an psychologist). One of
the institutions also has “Stop and think” as a specific manual-based method. The third
institution has a psychodynamic-/relation oriented theory and milieu therapy as method, but
offers other programs such as LEVA-program (a social skills developing program) and other
therapeutic meetings with key staff. All institutions offer schooling and a variety of activities
such as horseback riding, bowling, hockey, soccer, training to ride public transportation,
photography courses, creative writing and social skills training, etc. Through the SWOTanalysis1, similar threats, weaknesses, strengths and opportunities have been identified at the
three institutions, which includes the increased collaboration between different categories of
staff (i.e. management, teachers, psychologists and department staff) and between department
specific areas/modules (ADL, family/network work, school, method/treatment programs,
leisure activity, work/job training) will be central to the development. This implies the need to
create a greater consensus and organizational interaction model so that the activities within,
and between, these modules/areas have a more pronounced therapeutic purpose related to the
treatment plan – not only creating opportunities for young people to be motivated to schools
and education, but to serve as a base for a future profession.2
CONCLUSIONS AND PRACTICAL IMPLICATIONS
Based on the previous discussion, some key development areas, linked to how to view quality
of an institutional treatment setting treatment, and the complexity how to evaluate the core of
the treatment content, have emerged. In this, quality aspects are linked both to collaboration
between the institutions' internal (different staff categories, such as ward staff, health care
staff/nurses/psychologist and school teachers) (see figure 3 below) and external resources (the
employment office, psychiatry, regular schools outside the institution, social service agency
etc.). And further, we need to create a holistic approach viewing both specific treatment
methods (e.g. ART, CBT, Ono-to-One), and other pro-social activities such as school, ADL,
Family and network, work training, and positive leisure time activities, as equal important for
a positive treatment process outcome. This include to promote both ward/treatment staff,
specific therapists, and teachers making continuous SMART-goals3 with the young in
different life/key areas. This imply to measure the resident’s treatment progression in these
life domains over time. For this project, a 24/7-goalchecklist has been developed in the areas,
as shown in figure 3 below, based on previous checklists such as the Independent Living Skills
– A checklist for young people in care (New south wales, Family and Community Service);
the Independent living skills assessment tool, (Department of Social & Health Services,
Washington State, 2000/2006). Specific goals, in the checklist, are also found in theory and
1
A SWOT-analysis is used to evaluate the strengths, weaknesses, opportunities and threats of an organization.
See Degner & Ahonen (2014) and Degner & Ahonen (2015) for more specific data. For further discussions
concerning institutional treatment settings, see also Ahonen (2012) and Ahonen & Degner (2014).
3
A SMART-goal model describes what a goal should contain for it to be optimal, developing and reachable.
Each goal should be: (S) – specific), (M) – measurable, (A) – attainable, (R) – relevant, and (T) – time-based.
2
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research of the concept psychosocial maturity (e.g. Greenberger & Sørensen, 1974; Steinberg,
Chung & Little, 2004; but also see Bowlby, 1988 and Bronfenbrenner, 1979), and finally,
goals have been transformed from questions in the ADAD-manual4.
Figure 3. One way to organize the institutional for a 24/7-strategy – and in order to stimulate both evaluation of
the individual, as well as the level of internal cooperation between staff groups.
In sum, most young people (and adults) who are placed in state driven intuitions have
complex psychosocial problems in many different life areas/domains. This urge for
developing a research based, theoretical, and pedagogical content in both staff monitored and
non-staff monitored pro-social activities (e.g. education, work training, therapeutic programs,
social relationship- and practical skills training/ADL, fitness and sport activities, music,
cultural expressions, religion, cooking skills, and artistry), that mostly already exists in the
facilities. For this it is important, which is one goal of the 24/7-project, to develop a
model/guide (24/7-manual) that will, at an organizational level, guide the institutional
management to organize the facility treatment program, and enable to make an evaluation
design, both according to the eight principles mentioned earlier in the paper, as to each
resident’s individual development in the program. To clarify, the 24/7-manual will support the
implementation of a clearer theoretical and research-based framework that, taken together,
will form the cornerstone for psychosocial maturity, 24 hours a day, 7 days a week, in order to
increase psychosocial growth, and post-detention enhanced employability.
4
ADAD is an assessment instrument for young drug users and young people with social problems. The
instrument has been developed in the US in the late 1980s by Alfred Friedman and Arlene Utada (1989), and is
used by The Swedish National Board of Institutional Care.
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Jürgen Degner, Ph.D., and assistant professor in Social Work, Örebro University, Sweden.
//Scientific head of project//.
Lia Ahonen, Ph.D. in Social Work and assistant professor in Criminology, Örebro University
Sweden, University of Pittsburgh, USA.
//International coordinator and assistant researcher//.
The Swedish National Board of Institutional Care
The National Board of Institutional Care (Statens institutionsstyrelse, or SiS) is a Swedish government agency
that delivers individually tailored compulsory care for young people with psychosocial problems and for adults
with problems of substance misuse (at 25 institutions//Author comment). SiS provides care and treatment where
voluntary interventions have proved insufficient and care on a compulsory basis has therefore become necessary.
Orders for compulsory care are made by the Administrative Court (Förvaltningsrätten), on the application of
social services. SiS runs special residential homes for young people (särskilda ungdomshem), which receive
young people with psychosocial problems and problems of substance misuse and criminal behaviour. Care is
provided under the terms of the Care of Young Persons (Special Provisions) Act (LVU). Some of these
residential homes also care for young people who have committed serious criminal offences and who have been
sentenced to secure youth care under the Secure Youth Care Act (LSU).
SiS also operates 'LVM' homes (10 institutions//Author comment), which treat adults with serious problems of
misuse involving alcohol, controlled drugs, prescription drugs or a combination of these. Here, care is provided
under the Care of Substance Abusers (Special Provisions) Act (LVM). The LVM homes and special residential
homes for young people run by SiS are the only treatment facilities for adults with substance misuse issues and
for young people with psychosocial problems that have the right to forcibly detain individuals who have been
taken into compulsory care.
(From
web-page:
institutional-care/)
http://www.stat-inst.se/om-webbplatsen/other-languages/the-swedish-national-board-of-