Youth Intervention: Theory, Research, and Practice – Lecture 5 (UNIVERSITY OF AMSTERDAM)

When treating criminals in the past, severe punishments were used. Later, phrenology was used to diagnose people and electro convulsion therapy was used to treat people with a criminal history.

Durkheim stated that every society gets the criminality that it deserves. The cost of incarceration is higher than that of rehabilitation. Martinez stated that people who commit crimes should be locked up. According to him, it is impossible to treat criminals. Early (humane) treatment for criminals consisted of CBT. It was focused on treating the symptoms and did not include the families.

Static risk factors refer to risk factors that cannot be changed and are fixed. Dynamic risk factors refer to risk factors that are malleable. The interaction between risk and protective factors and the interaction between the individual and the environment is essential for criminality.

The age crime curve refers to criminal activity increasing during adolescence and peaking during late adolescence. This could be due to the maturity gap (i.e. a well-developed affective brain circuitry and a less developed prefrontal cortex control centre in the brain, combined with adult responsibilities).

The outcome of therapy is influenced by several factors:

• 40% of treatment outcomes is determined by factors outside of therapy (e.g. positive relationship with the partner).
• 30% of treatment outcomes is determined by common elements.
• 15% of treatment outcomes is determined by placebo effects.
• 15% of treatment outcomes is determined by specific methodology.

There is a lot of innovation in the therapy of juvenile delinquents. This includes real-time biofeedback treatment and virtual reality treatment. Group therapy consists of treatment of aggression (1), improving social skills (2), making moral choices (3) and help meetings (4). However, it can lead to a lot of peer contagion, making it typically ineffective.

There are different forms of systemic treatments:

• Functional family therapy (FFT).
• Multidimensional family therapy (MDFT).
• Multisystemic therapy (MST).
• Multidimensional treatment foster care (MTFC)

There are three stages of systemic treatments:

1. Build the foundation (i.e. creating therapeutic alliance; build motivation).
2. Work the themes (i.e. request change).
3. Seal the changes and exit (i.e. consolidate and cease treatment).

Building a therapeutic alliance takes time and it is important to be patient as the patients are typically not motivated to change. The alliance between the patient and all important people (e.g. parents; therapists; friends) and the alliance between these people is essential.

Understanding the common elements of treatments could render them more effective. Many treatments have common elements, yet a unique focus which allows for personalization. Knowledge of treatment mechanisms and identification of potent treatment techniques can support enhanced precision in matching systemic treatment to the needs of adolescents and their families.

There are six mechanisms (i.e. common elements) of systemic treatment:

• Engagement (i.e. building motivation).
• Alliance.
• Interactional focus (i.e. family communication improvement).
• Evaluation (i.e. assess and evaluate the situation to act swiftly).
• Here and now focus.
• Developmental process (i.e. foster developmental progress; individualize intervention).

There are several common techniques that are used in most systemic treatments:

• Reinforcement.
• Divert and interrupt (i.e. interrupt a negative interaction)
• Reframing (i.e. change meaning of situation).
• Limit setting (i.e. reward and punishment).
• Enactment.
• Anticipating and training for setbacks.
• Psycho-education.
• Assigning and reviewing homework.
• Working with boundaries.
• Problem solving.
• Monitoring.
• Reconnecting.
• Conflict management.
• Communication skills.
• Special time (i.e. quality time with the adolescent).
• Reviewing goals and progress.

Reframing (1), reinforcement (2), enactment (3) and reconnecting (4) are essential techniques. Enactment refers to directing family members to talk or interact together to observe and modify problematic transactions. Reconnecting refers to demonstrating that there was a good relationship in the past (e.g. showing photos of the patient as a young child).

Multisystemic therapy (MST) refers to a treatment for adolescents with severe antisocial behaviour and it includes their families. It aims to address multiple risk factors associated with juvenile offending at multiple levels (e.g. individual; family; peer). The factors that create barriers to the effective functioning of systems needs to be addressed and the intervention is delivered in ecologically valid environments.

In the treatment, the caregivers are seen as the main conduits of change and interventions focus on empowering them with the resources and skills they need to be more effective. The treatment attempts to surround the adolescent with a context that supports prosocial behaviour. The therapist needs to be available 24/7 to allow sessions at convenient times for the families and this allows the therapist to respond quickly to crises. The intervention is 3 to 5 months but is intensive. During the whole treatment, ecological strengths are identified and used.

The treatment consists of several steps:

1. Identification of problem behaviour and function, and ecological strengths.
2. Development of treatment goals.
3. Development of coherent conceptual framework of ecological factors that drive the problem.
4. Development of intermediary goals.
5. Identification and development of specific intervention strategies.
6. Assessment of advances and barriers of treatment effectiveness.

MST has treatment effects on delinquency (1), psychopathology (2), substance use (3), family functioning (4), peer relations (5) and out-of-home placements (6). There is a 63% reduction in recidivism and very long-term maintenance of the results. It is not clear whether the treatment works for youth with conduct disorder.

Multidimensional family therapy focuses on the family environment (1), extrafamilial environment (2), individual (3) and the parents (4). It aims to target all factors that can influence delinquency. It is essential to treat the family as well.

The effectiveness of MDFT can be assessed by randomizing people into treatments, giving the treatment and having a naturalistic follow-up phase afterwards, where people do not receive treatment but are regularly assessed.

Both MDFT and CBT decreased criminal behaviour significantly but MBDT better protected non-delinquent adolescents against starting to commit criminal offenses. For violent crimes, MDFT decreased violent crimes better than CBT but this is not the case for property crimes. MDFT works best for severe cases.

Meta-analyses demonstrate that MDFT can be used to treat delinquency. It has positive effects on delinquency (1), substance abuse (2), externalizing problems (3), internalizing problems (4) and family functioning (5).

A treatment for substance use disorder should consider the behavioural skill deficits (1), limited coping strategies (2) and emotion dysregulation (3) of the adolescents and the addictive and pharmacological properties of the different substances.

Functional family therapy (FFT) is a family therapy which sees substance abuse as behaviours that develop and are maintained in the context of maladaptive family relationships. It thus aims to change the family interactions and aims to improve relationship functioning. This treatment is able to target comorbid disorders. The treatment goals include reducing substance use and co-occurring problems (1), improving family relationships (2) and increase adolescents’ productive use of time (3). The treatment consists of 14 weekly 1-hour sessions with more frequent or longer sessions at the beginning to initiate change. It follows five methods in order:

1. Engagement
   This aims to maximize engagement to minimize attrition and is done by expressing positive expectations for change.
2. Motivation
   This aims to maximize willingness to change. This is done by emphasizing strengths (1), develop a relational framework (2), reframe or change the meaning of behaviours and interactions that are perceived negatively (3) and actively manage aversive interactions (4). The therapist needs to highlight the interactions between family members to increase awareness of how they affect one another.
3. Assessment
   This aims to set behavioural targets of change and determine how the change needs to occur to maintain the functions served by the behaviour. This thus includes a functional analysis of the behaviour (i.e. using drugs to receive more attention from the father) for each dyad in the family. Behaviours are assessed in terms of adaptive or maladaptive.
4. Behaviour change
   This aims to establish and maintain behaviour change at the individual and family level. The specific behavioural techniques used are determined by the motivational framework that has been created and by using the assessment data.
5. Generalization and termination
   This aims to facilitate maintenance of behaviour change and the generalization of treatment gains to the natural environment. The therapist gradually takes a less active role.

The treatment is effective in reducing recidivism and improving family functioning. It is effective for delinquency and youth disruptive behaviour and it reduces subtance use. The results appear to be maintained over the long-term and can be maintained through brief telephone counselling. It is also efficacious reducing depression and subtance use for youth with comorbid depressive disorders. The treatment is especially effective for adolescents from a Hispanic background if the therapist has the same ethnic background.

People who are psychopaths are antisocial and callous unemotional. They have several characteristics:

• They have no fear.
• They are stress resistant.
• They have no motivation for treatment.
• They are not affected by punishment.
• They feel no empathy or remorse.
• They are egocentric.
• They are superficial.
• They have a mask of sanity.

It can be checked using the Psychopathy Checklist-JV.