Treatment and Rehabilitation for Youth with Substance Use Problems

15. Additional Best Practices: Key Expert Perspectives

15.1 Staff Characteristics

Key experts were asked to identify other elements of treatment associated with positive treatment outcomes not discussed in the broad areas described above. A range of best practices was described, many replicating previous themes (e.g. harm reduction, client/treatment matching). A significant new theme that emerged was the importance of specific staff charcteristics as a factor related to treatment outcome and success. Staff qualities were described in relation to attitude, background and skills. In terms of attitude, key experts described the most effective therapists as being able to:

• show respect and trust;
  
• minimize the hierarchical power structure and work collaboratively with youth;
  Workers have to be respectful. They have to choose and want to work with youth, and like them. All the rest is teachable but that isn't. As adults, we need to know how to be comfortable with being challenged by them; we can't get into power struggles.
  
• build and maintain a positive rapport with clients over the long term (including after program termination);
  
• accept relapse and not define it as a failure;
• help youth redefine themselves in new, more positive ways;
  
• model a positive, healthy lifestyle.

The most important aspect of staff background defined by respondents was the ability to speak with familiarity (and experience) to issues of importance to youth. Direct familiarity with different cultures and issues related to sexual orientation were emphasized. In terms of specific staff skills, respondents stressed the need for staff to:

• be trained and qualified;
  
• understand youth developmental issues and changes;
  
• understand conceptual tools such as the "Stages of Change" model and motivational interviewing.

15.2 Involvement of Healthy Adults/Group Therapy

Key experts highlighted two aspects of treatment:

• the importance of involving other healthy, consistent adults in youth treatment (in addition to family);
  
• the value of group therapy as an important method of treatment.

Key experts favoured group therapy over one-to-one therapy. Supporting positive peer connections through group work was considered to be a very valuable component of clinical practice. However, it was also stressed that not all youth do well in groups.

15.3 Wider Scope of Treatment Availability

Key experts also noted that there was a lack of certain types of treatment resources and options for youth, making success difficult to achieve. Specific gaps were noted in the following areas:

• a lack of residential treatment, especially regionally based resources;
  
• specific treatment for youth with fetal alcohol syndrome/fetal alcohol effects (FAS/FAE);
  
• easy and timely access to treatment;
  
• treatment for gay and lesbian youth;
  
• gender-specific treatment.
  

Table 11: Best Practices: Additional Elements: Key Expert Perspectives

Areas of Best Practice	Key Expert Themes
Staff characteristics	Attitude: Respectful, shows trust Minimizes power structure Builds positive rapport during and post-programs Helps youths redefine new positive self Models healthy lifestyle Skills: Trained/qualified Understands youth and developmental issues Background: Awareness with issues important to youth (e.g. cultural issues, sexual orientation)
Additional issues	Non-family adult role models required in youth's life Value of group therapy Need to address gaps in services residential FAS/FAE increased accessibility treatment for gay and lesbian youth gender-specific treatment

15.4 Additional Best Practices: Literature Review

15.4.1 Staff Characteristics

The quality of the staff/client relationship has been identified in the literature as an important determinant of treatment success. In a review of several studies, Russell (1990) described specific staff characteristics which are likely to be related to successful youth treatment programs, and concluded that effective staff are:

• engaged with clients;
  
• relaxed and caring;
  
• able to be spontaneous;
  
• objective;
  
• likeable;
• able to "get down to the level" of adolescents;
  
• past their own adolescent issues but able to recall and be sensitive to them;
  
• able to project confidence.

Alexander et al. (in a study cited by Russell, 1990) indicated that it is the global quality of the staff relationship with clients that accounts for most outcome variance. Alexander et al. (as cited in Russell, 1990) concluded that relationship skills combined with a well-structured agenda and operational program framework are both essential to treatment success. Spooner et al. (1996) also attempted to define staff characteristics associated with optimal outcomes. Characteristics summarized from several studies include:

• a sense of humour;
  
• ability to be encouraging and reinforce positive behaviour;
  
• a lack of confrontation and directedness;
  
• the ability to develop a warm and supportive relationship with clients.

Luborsky (as cited in Spooner et al. 1996) found that the ability of a therapist to form a warm, supportive, therapist/client relationship, and a "helping-alliance" early in treatment was significantly correlated with the outcome. He also found that consistency in applying established treatment procedures was also correlated with treatment success.

A comparative study (McLellan et al. as cited in Spooner, 1996) of four different "types" of treatment providers found that the most effective were better organized, saw clients frequently, kept better case notes, were more consistent in their application of program policies and referred to specialists frequently. The most effective counsellors anticipated problems in each client's life and developed strategies in collaboration with clients to help resolve these problems.

In a study by Friedman and Glickman (as cited in Catalano et al. 1990 - 1991), 65 program variables were correlated with treatment outcomes. Staff-related variables showing significant correlation with treatment success were:

• number of years counsellors had worked in the counselling field;
  
• number of volunteer staff in direct contact with clients;
  
• degree of counsellor's use of practical problem-solving approach with client.