NUMBER 893 • 23 JANUARY • OFFENDERS IN RESIDENTIAL FACILITIES
The juvenile offender in residential treatment stands to benefit from many aspects of the RF, both in terms of formal treatment and the milieu that is the therapeutic community. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children and Adolescents with Conduct Disorder (AACAP, 1997) define the minimum psychiatric services that should be available in inpatient, partial hospitalization, and residential treatment, including the following:
- Therapeutic milieu, including community processes and structure (e.g., level system, behavior modification)
- Significant family involvement
- Individual and group therapy
- School programming
- Specific therapies for comorbid disorders
- Psychosocial skills training to improve social function
- Collaboration with outside agencies in preparation for a safe discharge
Because almost all juvenile delinquents are conduct disordered, these parameters are highly relevant to them. In addition, guidelines for the treatment of aggression in youths in residential facilities have been promulgated (dosReis et al., 2003). But, as the AACAP Parameters themselves note, there should be no single approach to all patients, and each patient in a residential program must be assessed individually, and comorbid diagnoses elicited and treated.
Individual psychotherapies. Almost all of the established individual psychotherapies have been used in the residential setting. Psychodynamic psychotherapy was used in the past (Aichorn, 1935; Trojanowicz, Marsh, and Schram, 2001), but it is not effective in isolation from other treatment modalities and may lead to increased aggression. Burke, Loeber, and Birmaher (2002) state, "By and large, isolated individual treatment of [disruptive behavior disorders] has not been proven to be a superior form of treatment. . . . Individual interventions may be most effective as a component of a broader treatment program addressing a variety of risk domains" (p. 1286). Many programs today focus on behavioral methods to promote social competence and prosocial behavior and reduce the negative influence of peer pressure (Arbuthnot and Gordon, 1986; Trojanowicz et al., 2001). Such methods may include awarding tokens or points for following rules (with loss of points for aggressive behavior, noncompliance with directions, and so on). Points are used to earn rewards or privileges.
Cognitive therapy has shown promise and is often used as part of multimodal treatment (Ross and Fabiano, 1985; Kazdin, 2000; Trojanowicz et al., 2001; Lester and van Voorhis, 2002). This form of psychotherapy targets thinking in relation to actions; its aims are to improve goal-oriented planning, understanding of others' behavior and motivations, social problem solving, and realistic appraisal of consequences.
The therapeutic community. Besides formal psychotherapies, the experience of being in the therapeutic community may play the most vital role in treatment or rehabilitation for RF participants. Treatment in an RF is, to a great degree, centered on the milieu and group experience (DeLeon, 2001). Staff who spend time with the residents have the greatest influence on them. Some workers have questioned whether it is disadvantageous to group multiple juvenile delinquents in such settings, because this can lead to negative effects such as reinforcement for antisocial behavior. For example, in outpatient treatment, there is a tendency to avoid placing more than one conductdisordered patient in a particular therapeutic group. The same has not been studied in RF participants. However, one recent study suggested that peers in RFs helped each other via the development of intimate relationships that led to improved academic and vocational performance and improved relationships with authority figures (Vincent, Houlihan, and Mitchell, 1992). Further study is needed to determine the qualities of RFs that lead to the best treatment.
Education. Given the high rate (35-65%) of learning disabilities among juvenile delinquents (Ingalls and Goldstein, 1999), attention to educational needs is an important component of the treatment as well.
Psychiatric care. The role of the psychiatrist in the RF varies by institution, ranging from consultant to medical director. In addition to performing the typical functions of psychiatrists in inpatient settings such as psychiatric evaluations, treatment planning, and medication management, the psychiatrist plays an important role by participating in risk assessment at discharge and by making recommendations for further care (e.g., in a community outpatient treatment program or a more restrictive environment, such as a detention center, residential program, or inpatient unit).
STEPHEN BILLICK and H. AVRAM