Treatment and Rehabilitation for Youth with Substance Use Problems

10. Client Retention in Treatment

10.1 Client Retention in Treatment: Key Expert Perspectives

10.1.1 General Comments

The literature suggests that retention of clients in treatment is an issue within a range of health-related services, including substance abuse treatment. It is generally accepted that clients who drop out of treatment early have a much greater likelihood of returning to problematic substance use (Stark as cited in Spooner et al., 1996). At the same time, there is a recognition that treatment drop-out is "normative" across all treatment modalities and that benefits may still accrue to short-term treatment involvement. Youth present a special case in treatment because they:

Tend not to voluntarily use treatment services. Most are coerced by their family, schools, the legal system or significant others. Often adolescents see treatment as unapproachable, irrelevant, frightening, distasteful or not very useful. (Spooner et al., 1996:72)

Some key experts involved in this study were critical of the concept of retention, believing that it is a "static" approach which does not reflect youth reality.

Youth are going through a process--a program doesn't have to retain them to be successful.

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Youth will return to a program while they are getting something out of it--programs need to honour that leaving is part of process.

Key experts identified best practices related to retention in the following areas:

• assessment and intake;
  
• program philosophy and approach;
• family outreach and involvement;
  
• program content;
  
• needs of specialized groups.

10.1.2 Assessment and Intake

Two aspects of assessment and intake were identified as best practices which support the retention of youth in treatment:

• The importance of (early stage) client/treatment matching, which considers and tries to match client readiness with treatment objectives and methods. Several respondents recommended the "Stages of Change" model as a tool to assist with client/treatment matching.

We need to match treatment to the stage youth are in, for example, we can't do treatment if youth are in the pre-contemplative stage.

• The importance of making available, both to the client and family, at intake detailed information about the program, presented in creative and interesting ways.

They get a booklet called "Welcome to ____" and it explains everything, such as phone privileges. There are no surprises.

***

We have a one-day treatment workshop for (treatment) resistant kids - they do role plays, have a pizza, do an evaluation and sometimes the kids see that it is not so bad to go here.

10.1.3 Program Philosophy and Approach

There was a strong consensus among key experts that both an understanding/acceptance of relapse and a focus on harm reduction are the optimal approaches to support youth retention in treatment. This dual approach (acceptance of relapse/use of a harm reduction model) was described in varying ways but appears to include these common elements:

• acceptance of youth relapse as an inevitable part of recovery;
  
• consideration of relapse not as a failure but as an opportunity to learn about substance use triggers and ways of reducing use;
  
• a need to focus on client life goals and the impact of substance use on these rather than primarily focussing on substance use;
  
• the development of a long-term supportive client - staff relationship which accepts and explores relapse;
• the presence of program strategies to support youth re-engagement in treatment, if and when relapse has occurred.

Coupled with this dual approach was strong key expert consensus on the value of a client-directed approach which supports client involvement in goal setting and treatment planning.

We set up a contract with the kid - s/he determines what to work on (like reduction in use or coping with family), what their indicators of success would be, frequency of sessions -this makes them feel in control.

A flexible approach to treatment outcome was also stressed. Treatment "success" is not always straightforward. Needs vary and youth learn at their own rate.

For various sub-groups of youth, structure and duration may vary - don't need to do anything different than allow youth to work at their own rate.

Finally, a respectful and supportive staff approach to clients was described as one of the most significant factors supporting retention of youth in treatment.

Don't rely on academic therapy if you truly value youth and believe in them and see them as really neat, bright survivors - really respect them, that goes a long way with them. Gets them to come in and to work. If they feel valued, then they feel valuable and will want to work on themselves.

10.1.4 Outreach to Families

There was broad consensus among key experts on the importance of actively involving the family in treatment. The engagement of even one family member (a sibling or one parent) is considered critical. It is recognized that families often have diverse needs (for therapy, education or support) which programs need to address. Sometimes early work with parents is the entry point for youth treatment.

We may work for one and a half years with parents or adult figures in a youth's life and hardly ever see the kids.

10.1.5 Program Content

Key experts identified a broad psycho-educational approach as the most optimal way of retaining youth in treatment (see Section 12.0 for more detail on treatment approaches). Coupled with this broad approach is the importance of providing a treatment environment that is safe, fun and which incorporates a range of recreational activities.

10.1.6 Needs of Specialized Groups

In most cases, general key expert comments also applied to youth in specialized sub-groups. However, several comments were made specifically related to these sub-groups. There was key expert consensus that:

• Street-involved youth/Aboriginal youth require, above all, a safe and secure treatment environment.
  
• Aboriginal youth require programs which incorporate traditional beliefs and practices from the Aboriginal community. There is a need for a component of treatment which addresses spiritual needs, practices and beliefs.
  

Table 7: Client Retention in Treatment: Key Expert Perspectives

Areas of Best Practices	Summary of Key Expert Perspectives
Assessment and intake	Importance of appropriate client/treatment matching (e.g. intervention matched to Stages of Change model) Availability of concrete (early stage) information about the program
Program approach	Harm reduction model Flexible, open-ended approach Respectful, supportive and engaged staff Understanding/acceptance and management of relapse Focus on broader life goals Staff able to re-engage youth in treatment if relapse occurs
Family outreach	Family involvement (at early stage) Assessment and addressing of diverse family needs
Program content	Broad psycho-educational approach Culturally appropriate activities Recreational component Safe environment Fun, creative

10.2 Retention in Treatment: Literature Review⁶

There is little available youth-oriented literature which specifically addresses treatment retention. However, retention issues are often addressed when considering treatment approaches, methods or effectiveness. Within the adult-oriented literature, the main predictors of retention include a mix of demographic, family and program variables. Spooner et al. (1996) summarized the factors most closely related to client retention in treatment.

• age;
  
• level of education;
  
• type of psychopathology (e.g. depression);
  
• degree of support from family and friends;
  
• level of prior substance abuse;
  
• living arrangements (whether stable or unstable).

A number of treatment program elements have been associated with (continued) retention in treatment (for adults). These include:

• continuous progress review and assessment;
  
• attention to psychological issues;
  
• attention to family needs;
  
• individual attention;
  
• increased attention to newer treatment clients (in residential settings) (Condelli and De-Leon as cited in Spooner et al., 1996).
  

Miller (as cited in Spooner et al., 1996), in a compilation of staff opinions, identified the elements of a program most likely to retain youth clients. The elements included high levels of support for client spontaneity, support for client activity and growth and autonomy, a practical and personal problem-solving orientation and encouragement for expression of feelings. A reasonable level of order and organization, program clarity and staff control (to ensure clients' safety) were also described. A safe environment was also thought to be applicable to longer-term retention.

Schonberg (as cited in Spooner et al., 1996) noted the importance of careful client/treatment matching in order to retain clients in treatment. Client treatment involves an assessment and weighing of multiple factors such as level of toxicity, withdrawal effects, consideration of medical, intrapersonal, interpersonal and environmental issues.

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⁶ Retention issues are also covered in Section 12.