Adolescents in Therapeutic Communities

Article excerpt

The literature examining success rates for milieu treatments of antisocial and conduct-disordered adolescents has been dominated by pessimism (Macallair, 1993). The "nothing works" position has provided little useful information for clinical practice and has cast an aura of "diagnostic gloom" (Wolff, 1984) over an increasingly large number of troubled youth (Wells, 1991a; Zimmerman, 1990).

It has been suggested elsewhere that the wholesale condemnation of residential treatment models is unwarranted (Curry, 1991; Small, Kennedy, & Bender, 1991). Upon closer examination, the literature is rife with methodological problems so that existing studies are generally inconclusive (Pfeiffer & Strzelecki, 1990; Wells, 1991b). Criteria for judging the success of client outcomes are poorly defined and lack standardization (Beschner & Friedman, 1985; Curry, 1991; Durkin & Durkin, 1975; Lewis & Summerville, 1991). Many studies rely on self-report data (Bale, 1979; Reed, 1978) or use single global indices of improvement that yield little meaningful information. The most common design is retrospective, with no reporting of baseline rates (Velasquez & Lyle, 1985). Overall, there is a sparsity of empirical work so the whole literature is dominated by theorizing rather than research activity, and research that has been performed has lagged behind the advances in other related fields (Curry, 1991). The complexity of treatments, the ethical drawbacks to random assignment, the tendency of client groups to be small and heterogenous, and the considerable latitude given to front-line staff in applying the treatment have all served to discourage planned research. One of the greatest obstacles to research has been that it is only recently that front-line staff have begun to see themselves as skilled professionals providing treatment that can be evaluated (DeLeon & Rosenthal, 1979).

This study was designed with the primary goal of examining the response to treatment in a Therapeutic Community for conduct-disordered adolescents. This model was originally designed for a milieu of drug addiction (Bratter, Collabolletta, Fossbender, Pennchia, & Rubel, 1985; DeLeon & Rosenthal, 1979) and stresses confrontation and self-governance by the clients themselves (Almond, 1974; Lennard & Allen, 1974). While Therapeutic Community treatment has been applied to adolescents, and initial results have been positive (Bescher & Friedman, 1985) research on this model is especially sparse. This study also represents an attempt to overcome a number of methodological flaws traditionally associated with research in residential treatment. Treatment outcome was compared for two theoretically distinct programs, the comparison of which was facilitated through the use of environmental measures. Multiple measures of client change were incorporated and administered at three separate intervals in the treatment process in a repeated measures design. Baseline rates were utilized to judge the comparability of the two treatment groups at admission.

METHOD

Study Setting

This study was conducted in two different publicly funded residential treatment environments. One program is a Therapeutic Community located within a large general psychiatric hospital (hereafter referred to as TC). It stresses self-regulation, peer confrontation, and the development of insight as necessary for behavior change. The second program is part of a public psychosocial (nonmedical) agency that provides out-of-home care and treatment to nondelinquent adolescents. It is run on behavior modification principles and uses a point system as the basis for a Token Economy. The staff at this unit (hereafter referred to as BU) expect behavior to change as a function of reinforcements and consequences.

In order to obtain an objective index of the differences between the two programs, the Correctional Institutions Environment Scale (Moos, 1974) was administered to all staff in both programs. …