Motivating institutionalized adolescents for psychotherapy

In the study of psychotherapy, one surely must come to appreciate the importance of client motivation. Intuitively, its value in obtaining a successful outcome would seem unquestioned. Nonetheless, motivation for treatment has not received the attention in the literature that its importance might warrant. This paper deals exclusively with the adolescent and in particular, the institutionalized adolescent. Often members of this population become known as "untreatable cases" and attempts at treatment result in frustration from emotional and economic drain. This paper reviews the literature regarding client motivation, client preferences, and token economies, and offers recommendations for designing a program to increase motivation for psychotherapy in institutionalized adolescents.     

Restraint and seclusion with institutionalized adolescents

Tens of thousands of the nation's young people are placed in psychiatric and criminal justice programs annually. Within those settings, many confront an assortment of restraint and seclusionary measures. This paper discusses the population of young people exposed to such procedures and examines the implications within these settings and elsewhere.     

Group psychotherapy for adolescents comorbid for substance abuse and psychiatric problems: a relational constructionist approach

The group psychotherapy of adolescents comorbid for psychiatric and substance abuse problems is fraught with inconsistent attendance, frequent verbal and physical disruptions by the adolescents, and intense countertransference toward patients and their parents on the part of treating staff. A relational constructionist approach assists staff and patients in overcoming these obstacles and in focusing on the adolescents' search for personal meaning. Multiple group psychotherapy conducted in a combined day treatment and high school program is described and illustrated by case examples during the course of a year of treatment. These examples illustrate the importance of a relational non-hierarchical approach to adolescent patients by treating staff.     

A token reinforcement system for large wards of institutionalized adolescents

Problems associated with the application of token systems to large public institutions for male and female adolescents are discussed. The present experiments demonstrate that two specific behavior problems on an adolescent ward of a state hospital could be controlled through the use of contingent points via a rapid-delivery token procedure and backed up by reinforcers already available in the hospital setting. Sixty male and female patients were maintained by a staff of five aides. Experiment I examined the effects of verbal demands and contingent points on room maintenance behavior. Experiment II examined the effects of verbal demands and contingent points on ward maintenance behavior. Contingent points produced substantial effects on both types of behavior. Several design criteria are elaborated which facilitate working within the limitations of a setting with low priorities on research.     

Preventing and reducing substance use among institutionalized adolescents

The Residential Student Assistance Program, serving high-risk, multiproblem, inner-city, primarily African-American and Latino youth, was evaluated for its ability to prevent and decrease alcohol and other drug use. Participants were drawn from several adolescent residential facilities: three foster care sites for abused, neglected, orphaned, or troubled adolescents, a nonsecure facility for adjudicated juvenile offenders, a treatment center for teens with severe psychiatric problems, and a locked county correctional facility. In addition, comparison groups were employed. A 5th-year outcome evaluation documented the program's effectiveness in both preventing and reducing substance use among participants, with impact related to program dosage. Qualitative process data clarified and strengthened confidence in the quantitative outcomes.     

Social skills training for young adolescents

A systematic assertiveness training program was developed for adolescents, based on Albert Bandura's social cognitive theory. The program, which focused on peer interactions and social responsibility, consisted of six 40-minute semi-weekly sessions and was presented to a class of 22 sixth-grade social studies students in a middle school. Cognitive acquisition of the information was measured with multiple-choice tests administered immediately after training and at a 6-month follow-up. Trained students performed significantly better than a control group on the posttest (p less than .01) and on the 6-month follow-up (p less than .02), demonstrating that young adolescents can acquire and retain the symbolic information that forms a basis for assertive behavior.     

A rapid method of toilet training the institutionalized retarded

Incontinence is a major unsolved problem in the institutional care of the profoundly retarded. A reinforcement and social analysis of incontinence was used to develop a procedure that would rapidly toilet train retardates and motivate them to remain continent during the day in their ward setting. Nine profoundly retarded adults were given intensive training (median of four days per patient), the distinctive features of which were artificially increasing the frequency of urinations, positive reinforcement of correct toileting but a delay for "accidents", use of new automatic apparatus for signalling elimination, shaping of independent toileting, cleanliness training, and staff reinforcement procedures. Incontinence was reduced immediately by about 90% and eventually decreased to near-zero. These results indicate the present procedure is an effective, rapid, enduring, and administratively feasible solution to the problem of incontinence of the institutionalized retarded.     

A Spiritual Issues Discussion Group for psychiatric in-patients

This article describes a weekly Spiritual Issues Discussion Group, co-led by the author, open to psychiatric in-patients at New York Presbyterian Hospital. The group is open to people of all faiths and endeavors to allow participants to explore the many relationships between their beliefs, past experiences, mental illness, and spiritual lives. The article also summarizes the professional literature reporting on similar groups and suggests areas for further study.     

Reliability of the Behavior Problem Checklist with institutionalized male delinquents

Interrater and 2-week test retest reliability coefficients were determined for subscales of the Behavior Problem Checklist on 50 males incarcerated in a state receiving facility for delinquent adolescents. Raters were 22 dormitory counselors, 2 of whom rated each child after 1 week and again after 3 weeks of observing the boys. Interrater reliability ranged from .06 to .68 on the various BPC subscales and was .50 overall, reflecting wide variation in the agreement of raters in rating boys on different dimensions. Test-retest reliability coefficients for the same rater at 2-week intervals were higher (.71 overall) and also varied among subscales. Raters were able to agree best on aggressive, acting-out behaviors. Other personality dimensions tapped by the BPC were rated with less reliability in this particular setting.This research was conducted with the cooperation and support of the Alabama Department of Youth Services, Diagnostic and Evaluation Center, Mt. Meigs, Alabama.     

A prevocational training project for emotionally disturbed adolescents

Adult inpatient populations, trained to develop a repertoire of work-related skills such as tracking and following directions, utilizing emotional controls, relating to the world in a realistic manner, as well as acceptance of supervision, grooming, punctuality, and attendance. These skills eased their transition to the community and assisted in a more positive existence once within that community as compared to their untrained cohort. Additionally, the process of vocational training has been demonstrated to have therapeutic benefits. This project used many of the same adult training principles but applied them to an adolescent inpatient population. A vocational training project using specific behavioral interventions resulted in comparable improvement for adolescent subjects otherwise evidenced in adult patients' work-related skills and abilities. This training project was conducted yearly, 32 h per week for 10 weeks for 4 years. The project combined actual work experience, classroom time and behavioral interventions and rewards. A 16 × 10 analysis of variance was computed to assess improvement in work-related skills and abilities. The analysis yielded and F = 2.57, p < 0.01, suggesting the efficacy of the behavioral interventions when applied to adolescent inpatient populations. © 1997 John Wiley & Sons, Ltd.     

Crisis prevention and intervention training for psychiatric hospital staff

A 5-day course designed to train psychiatric hospital staff verbal and physical methods of preventing violence and injury when dealing with upset patients was taught to 89 staff from maximum and less secure wards. Compared to no-treatment controls, experimental subjects improved significantly on four tests of crisis-related tests and knowledge. Questionnaire and self-report measures from staff and patients on the training wards also indicated positive course effects. Assault frequencies decreased immediately after the course and staff injuries on experimental wards were reduced after the course relative to control wards.     

Attitudes of adolescents toward adolescent psychiatric treatment

Perceptions held by adolescents about the value and social stigma of both psychiatric hospitalization and outpatient therapy for adolescents are examined. Perceptions about preferred forms of treatment for specific adolescent problems are also analyzed. The results indicate that attitudes are significantly influenced by proximity to treatment setting, i.e., adolescents currently being treated are more positive than adolescents who have been previously or never treated. Contextual and attributional explanations are considered.     

Family systems training in psychiatric residencies

Both extensive research and common sense dictate that attention to families is necessary for appropriate care of psychiatric patients. However, training in family skills has often been difficult to integrate into psychiatric residency programs because of conflicting paradigms, turf battles, constraints of time and money, and confusion over whether family-centered care or family therapy should be taught. Current changes in residency accreditation mandate that family skills (not necessarily family therapy in its sophisticated form) be part of all residency programs. This article reviews the history of systems training in residencies, current accreditation requirements, and the GAP proposal for family systems skills, knowledge, and attitudes that that are teachable within the limited time available to residents. The application of these core skills is described using a case example and formulation. Challenges in teaching and ways of overcoming programmatic constraints are outlined.