Therapeutic recreation interventions in substance abuse treatment programs.

The 1990 conference on the efficacy of therapeutic recreation, culminating in the publication of the text entitled Benefits of Therapeutic Recreation. A Consensus View, was a milestone in the field. Summarizing the results of the three-year project, Rancourt (1991) analyzed the literature to date concerning therapeutic recreation interventions in substance abuse treatment, and called for further research in the following areas: interdisciplinary research; research concerning ethnic groups; life span issues; longitudinal studies; gender research; and outcome research.

Other recommendations included research on theory based interventions, a focus on student drug use and abuse, the relationships between drug use and stress, poly-drug use, and the effectiveness of self-help groups. Methodology suggested included descriptive research to develop a body of knowledge, outcome research, with follow-up studies extending 18-24 months, qualitative research, and inductive, exploratory, and experimental (controlled) research.

Based upon these needs and suggestions for future research from 1991, a comprehensive literature search was undertaken to assess the "state of the art" of research on the use and effectiveness of therapeutic recreation interventions in substance abuse treatment programs published in 1991 and subsequent years. The majority of the research at this point in time is either theory-based and programmatic, or descriptive. There are many and varied published approaches to therapeutic recreation program planning in this specialty area, but space allows only for review of a selected few.

Theory Based Intervention

Pearson (1992) and Aguilar and Munson (1992) present theory and rationale for the inclusion of leisure education and counseling within substance abuse treatment programs. Pearson bases his model upon the literature on addiction and lifestyle, as well as upon leisure research indicating negative attitudes toward leisure and lower activity participation rates of persons addicted to alcohol. He reviews literature also cited in Rancourt (1991) indicating that involvement in leisure and recreational pursuits has been associated with recovery. A needs based model for leisure education is developed by Pearson, which is implemented within an interdisciplinary treatment approach. Pearson reiterates the need for thorough assessment of leisure satisfactions, history, and interests.

Aguilar and Munson focus on the needs of adolescents who abuse substances. They state that correlational research has provided support for theories of progressive substance use and social skills deficits in adolescents, but causal research is still needed to investigate motivational factors.

Their approach is based upon psychosocial theories of both substance abuse and leisure, including theories of Newlinger and Iso-Ahola (cited in Aguilar & Munson, 1991) on definitions of leisure and substitutability of leisure experiences respectively. Aguilar and Munson reiterate the importance of leisure as a critical component for both substance abuse prevention and intervention.

Another theory-based programmatic approach was that of Francis (1991) who based his recommendations upon Czikszentmihalyi's theory of flow (1975, cited in Francis, 1991). This state of optimal psychological arousal can be achieved in activities "where challenges and skills are ideally matched" (Francis, 1991, p. 42). Francis compares the experiences of euphoria stimulated by mood-altering substances and by recreational activities. He reiterates characteristics of substance "misusers" which have been reported consistently in the literature: stress; inadequate self-esteem and self-concept; leisure dissatisfaction; and boredom. He further recommends strategies for facilitating flow states for substance misusers.

Family dysfunction is another component appearing consistently in the substance abuse literature. Baker, Harding and Hadwen (1994) report a family component in their therapeutic recreation program for the treatment of chemical dependency. A family leisure education program, The Family Lab, has been developed by Malkin, Phillips, and Chumbler (1991). This program is based upon theories of substance abuse, leisure education and code-pendency, and involves a inter-disciplinary program including assessment, parenting training, family leisure education, and experiential activities.

Interventions focus on issues of enjoyment, trust, emotions, and communications. A final theory-based program is that of Malkin (1993) concerning intervention and treatment for cocaine-affected infants and children. Based on child development theory and the medical literature, interventions recommended include "baby holders," family interventions, and teaching strategies to deal with the myriad of physical, emotional, social and cognitive difficulties experienced by these children.

While these and other programmatic approaches appear to be grounded in relevant theoretical bases, there is little evidence that empirical studies have been conducted to date in order to validate the outcomes of such programs in substance abuse treatment.

Descriptive Research

The research which does exist is largely descriptive. This is of course, a first step in establishing a "body of knowledge" in the field as called for by Rancourt (1991) as noted above.

A number of studies have examined the providers and provision of leisure, activity and therapeutic recreation services in substance abuse treatment programs. Malkin, Voss, Teaff, and Benshoff (1993/1994) examined the role and function of recreational and activity therapists in substance abuse treatment programs with emphasis on agency characteristics, staffing characteristics, activity program characteristics, and numbers of and availability of Certified Therapeutic Recreation Specialists.

In this national study, responses were received from agencies representing the treatment modality spectrum (Inpatient, outpatient, residential care, etc.) with the bulk of the respondents providing residential services. Most therapeutic activity programs were supported by agency overhead costs, or direct billing, with no activity services supported through grants or fundraising.

The great majority of the agencies were accredited by either the Joint Commission on Accreditation of Healthcare Organizations or the Commission on Accreditation of Rehabilitation Facilities. Certified Therapeutic Recreators (Specialists and Assistants) greatly outnumbered non-certified or other professional providers in nearly all types of activity therapy programs. Twenty-six different types of activity therapy programs were offered, headed by physical fitness programs, leisure education, and stress management /relaxation programs. This study by Malkin, et al. (1993/1994) revealed that activity therapy is a vital and significant component of substance abuse treatment.

In a related study, Kremer, Malkin, and Benshoff (1995) surveyed practicing therapeutic recreation specialists to determine the types of physical activity programs offered as part of substance abuse treatment. Therapeutic recreations specialists or activity therapists affiliated with Therapeutic Recreators for Recovery, a national network of recreation professionals in the substance abuse field, comprised the study sample. Information was sought concerning employment characteristics, program characteristics, and types and numbers of physical activity programs provided in substance abuse treatment. Respondents worked in both in-patient and out-patient agencies and most often reported their titles as recreation or activity therapists.

Sixty-four percent claimed certification through the National Council for Therapeutic Recreation Specialist. About half of the participants worked in not-for-profit agencies, and about a quarter were employed either by government agencies or for-profit organizations. The leading physical activity programs, as reported by at least 50% of the respondents, included walking, games, sports, weight training and aerobics.

In their discussion of the findings, the authors noted the evolving significance and contributions of physical activity programs in substance abuse treatment, and noted the importance of additional research and program evaluation to document and validate program outcomes. They noted that the increasing demands and scrutiny of insurance carriers and accrediting and licensure groups give impetus to the importance of measurable outcome data.

The availability of therapeutic recreation services for adolescents in substance abuse treatment was investigated by Nation, Malkin and Benshoff (in press). A sample selected from the National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs was asked to provide information about facility and staffing characteristics, and therapeutic recreation programming. Unlike the adult facilities surveyed in other studies, fewer than half of the 49 responding facilities for adolescents offered therapeutic recreation programs. Moreover, adolescent facilities are less likely to employ certified recreation personnel, averaging less than one full-time equivalent position per agency, and respondents cited staff shortages as a major inhibiting factor in the development of activity programs.

Adolescent programs tended to emphasize leisure education and counseling, sports, and community leisure activities designed to build self esteem and self efficacy, improve levels of cooperation and trust, and improve basic social skills. The authors noted the absence of significant outcome information for physical activity programs for adolescents in substance abuse treatment, and stressed the importance of gaining additional information about outcomes and the roles and functions of certified recreation professionals.

Several researchers have examined specific issues or programs concerned with the provision of recreation services to individuals identified as having substance abuse problems. McNoriell (1992) asserted that a history of leisure lifestyle activities provided study participants with improved coping skills and problem solving skills. In addition, there appeared to be a positive relationship between the number of leisure activity skills possessed by study participants and the number of biosocial skills.

In a paper presented at the European Scientific Association on Residential and Foster care for Children and Adolescents, Duindam (1991) commented on the importance and evolution of outdoor programs for adolescents with addiction disorders, and noted the research findings are noteworthy for their absence of negative results. Brown et al. (1993) reported that few cases of substance abuse were identified among Choctaw Indian children following implementation of a youth demonstration program that included both drug education and recreation. She noted that a comprehensive external evaluation program revealed the effectiveness of the program for the participating youth. In contrast, overall community substance abuse had not declined.

Multicultural and Interdisciplinary Issues

There is a shortage of studies that address ethnic and multicultural considerations, as well as gender issues. Exceptions are the study mentioned above concerning Choctaw Indian children, and a programmatic approach (Ormond, 1992) which concerns the substance abuse of inner city African American males. This program includes a focus upon therapeutic recreation, family, and psychosocial skills.

One other issue noted by Rancourt in 1991 was the need for interdisciplinary research. From a review of the literature it is clear that most programs or interventions are interdisciplinary in nature. The interdisciplinary nature of the reported research is indicated by publication in a wide variety of literature, including the leisure, therapeutic recreation, substance abuse, correctional, rehabilitation, and career services journals.

Related Issues

Emphasis upon underserved persons is evidenced by publication of articles in the Journal of Healthcare for the Poor and Underserved. There is some evidence in Inciardi, Lockwood, and Hooper (1994) and Weekes, Millson, Porporino, and Robinson (1994) reviewed below, of longer follow-up periods, as recommended for study of substance abuse across the life course. Finally, attention to issues affecting student patterns of drug use and related decision making was recommended. There have been recent national studies descriptive of both high school and college students drug and alcohol use and abuse (Presley, 1995), but little efficacy research has been reported concerning substance abuse TR interventions for these groups.

Efficacy Research

In order to review the efficacy research concerning therapeutic recreation treatment interventions in substance abuse treatment, a thorough search of the computerized data bases was undertaken. Expanded Academic Index, Medline, Psychlit, Sociofile, and ERIC searches were conducted pairing such word combinations as "program efficacy," "substance treatment programs," "therapeutic recreation," "recreation therapy," and "program outcomes." Few studies were located examining program efficacy for substance abuse treatment programs that were not previously reviewed by Rancourt (1991) in Benefits of Therapeutic Recreation.

The Delaware Department of Corrections (Inciardi et al., 1994) has implemented two follow-through programs for drug offenders who have participated in rehabilitation programs. The programs are founded on the belief that treatment should be holistic, centered on total personal development, and therefore should be engaged in a therapeutic community setting. The primary goal of such treatment protocols is to alter the negative patterns of behavior, cognition, and affect that predispose individuals to drug abuse.

The Key program (Inciardi et al., 1994) in Wilmington, Delaware, provides various therapeutic treatments, such as behavioral, cognitive and emotional therapy in three treatment stages. Techniques used to assist individuals in developing motivation and positive social values may include transactional analysis, psychodrama and other therapeutic branch groups.

The Crest Outreach Center (Inciardi et al., 1994) was established as the country's first work release therapeutic community, assisting both men and women in a five-stage treatment process. The five phases employ sessions dedicated to educating persons about therapeutic community and integration, leisure education, leisure awareness, group cooperation, vocational education, and activities of daily living. Because the Crest program graduates have parole or probation stipulations after work release, an after care component was added to ensure graduates to fulfill parole or probation responsibilities. Such a program provides continued treatment services and hopes to reduce the risk of relapse and recidivism.

Current studies are being conducted by the University of Delaware to evaluate the program effectiveness of the Key and Crest (Inciardi et

al., 1994). At a six-month follow-up study, of the 151 clients in a non-treatment release comparison group, 34.4% were drug free. However, of the 24 graduates from the Key program who did not attend Crest but continued through conventional work release programs, 54.5% remained drug free. Of 75 individuals who completed the Crest without prior treatment, 83.3% were drug free. Finally, of the 20 individuals who graduated from both Key and Crest programs, 90% claimed to be drug free. Such data supports that individuals who have participated in primary and secondary phases of the treatment process were more likely to be drug free at the end of six months than any other group. (An 18-month follow-up study is currently in process.)

In Kingston (Ontario, Canada), the Offender Substance Abuse Pre-release (OSAP) Program has been designed to offer a comprehensive cognitive-behavioral program for offenders with moderate to severe substance and drug abuse (Weekes et al., 1994). This particular program serves a primary goal of educating offenders about abuse, teaching social skills related to appropriate behavioral functioning, encouraging autonomous decision-making skills, and implementing leisure and lifestyle planning.

A total of 324 adult offenders participated in the OSAP program. Weekes, Millson and Porporino (1994) reported that over 90% of the offenders who completed the program were released. Following release, offenders were followed for a period of 15 months. During this period, 30.2% of the individuals released were readmitted into custody. 73% of those readmitted had used drugs/or alcohol while on release and that substance abuse had contributed to their readmittance.

Readmission rates were directly related to severity of substance abuse. Only 20% of offenders in the low-level problem category were readmitted. Furthermore, recidivism rates dropped as improvement on a number of functional areas was noted. It is important to note that even these results cannot be attributed specifically to the recreational or leisure components of this multi-modal intervention, due to the multi-faceted approach. Although the study lacked a comparison group, the results surrounding the cognitive-behavioral substance abuse treatment program are encouraging in aiding substance abuse offenders in community re-integration and rehabilitation.

Conclusions

Participation in recreational and physical activity programs has become an integral facet of substance abuse treatment. Organizations such as the Joint Commission on Accreditation of Healthcare Organizations UCAHO) and the Commission on Accreditation of rehabilitation Facilities (CARF) have characterized therapeutic recreation as essential to comprehensive, quality care.

Services for alcoholism and drug dependency are continuously evolving and growing more sophisticated, and leisure and recreational skills programming are believed to be essential for successful, ongoing recovery. Wolkstein (1996) asserts the importance of leisure skills for such diverse concerns as self-esteem, time management, relapse prevention, and stress reduction, and calls specifically for consultation and involvement with certified therapeutic recreation practitioners.

In conclusion, there is some evidence that the research suggestions published in the Benefits of Therapeutic Recreation (1991 text) have been followed during the period 1991-96. Specifically evident are descriptive studies which have sought to analyze the "state of the art" in TR treatment, the development of theory-based interventions, and some focus upon issues such as ethnic groups, student use and abuse, longitudinal studies, and interdisciplanary research. There is a death of studies concerning substance abuse and gender in therapeutic recreation.

It is surpasing, however, given the demands of credentialing groups, and the asserted importance of leisure/ recreational programming in the recovery process, that so little outcome research exists in the therapeutic recreation, substance abuse treatment, or rehabilitation literatures. Clearly there is a demand for these services; and further more there is an implicit belief that they work and are valued parts of the treatment process.

The few existing studies present generally positive results, however their results cannot be attributed solely to the therapeutic recreation component of the interventions. The limited research available about the outcomes of recreation, leisure, and activity services in substance abuse does not bode well for the future. Increasingly, insurance carners, state licensing and monitoring groups and managed care organizations are demanding outcome-based measures of client success. The failure to provide this research data may have serious negative consequences for continued support of therapeutic recreation interventions in substance abuse treatment programs.

References

Aguilar, T. E., & Munson, W. W. (1992). Leisure Education and Counseling as Intervention Components in Drug and Alcohol Treatment for Adolescents. Journal of Alcohol and Drug Education, 37, 23-34.

Baker, J. K., Harding, S. C., & Hadmen, D. K. (1994, Winter). The Role of Recreation in the Treatment of Chemical Dependency: An Analysis of the Homewood Alcohol and Drug Service. Journal of Leisurability (pp. 20-26).

Brown, M. M., & Others (1993, November). External Evaluation of the Mississippi Band of Choctaw Indians' OSAP High Risk Kuth Demonstration Project--Year Two. Paper presented et the annual meeting of the Mid-South Educational Research Association, New Orleans, LA.

Coyle, C. P., Kinney, W. B., Riley, B., & Shank, J. W. (Eds.) (1991). Benefits of Therapeutic Recreation: A Concensus View Philadelphia, PA: Temple.

Duindan, T. (1991, November). Experiential Education, Outdoor Adventure as a Modality in Residential Treatment A Survey of Program, Principles, Research and Practice. Paper presented et the European Association on Residential and foster care for children and adolescents, Leeuwenhorst, Noordwijkerhout, Netherlands.

Francis,T.11991). Revising Therapeutic Recreation for Substance Misuse: Incorporating Flow Technology in Alternatives Treatment. Therapeutic Recreation Journal 25(2), 41-47.

Inciardi, J. A., Lockwood, D., & Hooper, R. M. (1994, February). Thorough Therapy: Delaware Treatment Program Presents Promising Results [CD-ROM]. Corrections Today, 56, 34-38. Abstract and full text from: Expanded Academic ASAP: A15204294

Johnson, L. D., O'Malley, P. M., & Bachman, J. G. (Eds.) (1995). National Survey Results on Drug Use From The Monitoring the Future Study, 1995-1994, (Vol. 1) Rockville, MD: NIDA.

Kremer, D., Malkin, M. J., & Benshoff, J. J. (1995). Physical Activity Programs Offered in Substance Abuse Treatment Facilities. Journal of Substance Abuse Treatment, 12, 327-333.

Malkin, M. J. (1993). Recreational Therapy and Cocaine Affected Children. Expanding Horrors in Therapeutic Recreation,

Malkin, M. J., Phillips, R. W., & Chumbler, J. A. (1991). The Family Lab: an Interdisciplinary Family Leisure Education Program. Annual in Therapeutic Recreation, 2 25-36.

Malkin, M. J., Voss, M. C., Teaff, J. D., & Benshoff, J. J. (1993/94). Activity and Recreational Therapy Services in Substance Abuse Treatment Programs. Annual in Therapeutic Recreation, 2, 40-50.

McNoriell, C. R. (1992). Play, Recreation and Hobbies as Constructive Leisure Activities by Troubled Individuals and Groups: Biosocial Skill Building (Doctoral dissertation, Wayne State University, 1992). Dissertation Abstracts International 53,1666.

Nation, J. M., Benshoff, J. J., & Malkin, M. J. (In press). Therapeutic Recreation Programs for Adolescents in Substance Abuse Treatment Facilities. Journal of Rehabilitation.

Ormond, J. E. (1992). A Paradigm for Socialization: Empowering African-American Substance Abusers to Maximize Their Human Potential. Journal of Health Care for the Poor and Underserved, 3(1), 181-193.

Pearson, O. M. (1992). A Leisure Counseling Model for Addicted Persons. Journal of Career Development, 19(11), 13-24.

Presley, C. A., Meilman, P. W., & Lyerla, R. (1995). Alcohol and Drugs on American College Campuses: Use, Consequences, and Perceptions of the Campus Environment (Vol. Il: 1990-92). Carbondale, IL: Southern Illinois University, Core Institute.

Weekes, J. R., Millson, W. A., Porporino, F. J., & Robinson, D. (1994). Substance Abuse Program Analyses Rates of Success. Corrections Today, 5611), 86-89.

Wolkstein, E. (Ed.). (1996). Substance Abuse, Disability and Vocational Rehabilitation. Dayton, OH: Rehabilitation Research and Training Center on Drugs and Disability, Wright State University.

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