Therapeutic recreation programs for adolescents in substance abuse treatment facilities.
According to Newcomb and Bentler (1988), the use and abuse of psychoactive chemicals, including illicit drugs, alcohol, prescription and over-the-counter medication and cigarettes has become a major national and international problem affecting all segments of society. Embedded within the context of this growing problem is the use and abuse of drugs and alcohol by youth. A 1990 report issued by the National Institute of Mental Health stated that America is wasting its most precious natural resource: its children and youth" (Babor, Del Boca, McLaney, Jacobi, Higgins-Biddle, & Hass, 1991, p. 77). Babor et al. (1991) report that over 12 percent of America's children and adolescents suffer from mental disorders, many of which are associated with drug and alcohol use, and substance abuse has been implicated in increased rates of adolescent suicide, violence, and homicide (Hanson & Venturelli, 1995). Alcohol and drug related accidents are the number one cause of death for adolescents and young adults in this country (Edwards, 1989). Indeed, Center for Disease Control statistics (Cited in Edwards, 1989) demonstrate a continuing trend of shortened life expectancy for persons ages 15 to 24 clearly related to alcohol and drug use. It has been noted (Newcomb & Bentler, 1988) that adolescent experimentation is not the issue; real concerns emerge when the experimental use leads to regular use or abuse.
Newcomb & Bentler (1988) have asserted that teenagers who use psychoactive chemicals may inhibit important developmental tasks and growth may be stunted or delayed. Other risk factors related to alcohol and drug use include environmental, behavioral, psychological, and social attributes (Newcomb & Bentler, 1988). The 1992 and 1993 National Household Survey on Drug Abuse (SAMHSA, 1995) confirm recent increases in drug abuse by youth and "reveal that many of these young substance abusers are experiencing significant problems because of their use" (p. 9). Furthermore. a recent study of alcohol and drugs on American college campuses (Presley, Meilman, & Lyerla, 1995) reiterates that alcohol and drug use on campus negatively effect individual students and the entire campus community. Alcohol continues to be most common drug of choice for college students and the heaviest drinkers receive the lowest grades. Students perceived legal difficulties. violence, and suicidal thoughts as consequences of drinking, and binge drinking was a prevalent pattern of use. Other drugs used frequently were tobacco and marijuana (24.2%). Significantly, more than 50% of students responding to this national survey were under 20 years old.
Many programs have been developed to promote prevention, or to provide treatment for adolescents with substance abuse problems. The models of substance abuse treatment for adolescents have emphasized treating the "whole person" and the need for overall lifestyle change (Kunstler, 1992). However, Babor et al. (1991) report that while progress has been made in the development of treatment services, the complex child and adolescent service system is expensive, uncoordinated, and of unknown effectiveness.
Therapeutic recreation has become a prominent modality in substance abuse treatment programs, but its role, according to Kunstler (1992), may not be fully realized. Hawkins & Catalano (1985) reported that the involvement in active recreational leisure activities shows a consistent positive relationship to reduced drug and alcohol use and physical activity and exercise can be beneficial in the treatment of substance abusers (Murray, 1986).
One of the primary purposes of therapeutic recreation is to encourage participation in non-psychoactive chemical activities where abusers can learn to experience fun and pleasure while feeling in control (Kunstler, 1992). Some of the deficit areas of individuals who abuse substances are their lack of stress management techniques, social skills, and assertiveness (Kunstler, 1992). All of these areas are addressed in leisure education programs and may be ameliorated through recreation participation. According to Kunstler (1992), recreational activities require skills for participation, have rules and goals, provide immediate and concrete feedback, and offer novelty and opportunities to experience control.
Kunstler (1992) also pointed out that lack of involvement in active recreation.. along with absence of a positive social network and inability to cope with stress, can cause relapse. However when exposed to leisure alternatives, clients in substance abuse treatment are more likely to participate in positive recreational opportunities after discharge.
Consequently, it is relevant to more closely and empirically examine the development of a therapeutic recreation program component in the treatment of adolescent substance abusers. Although the literature suggests the importance of recreational therapy as a treatment component for substance abusers very little research has been done to determine what therapeutic recreation programs are offered to adolescents in substance abuse treatment facilities.
Purpose and Research Questions
The purpose of this study was to determine the extent and focus of therapeutic recreation programs offered within substance abuse treatment facilities for adolescents. Specifically, it sought to determine: (1) the nature of leisure/recreation programs being offered to adolescents in substance abuse treatment programs; (2) the job titles and roles of staff members offering therapeutic recreation programs; (3) the goals of those leisure/recreation programs in these facilities and; (4) factors which inhibit the development and initiation of a comprehensive therapeutic recreation program.
Description of Sample
A random sample of 250 substance abuse treatment facilities was drawn from the 1992 National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs, published by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. Facilities from all fifty states were included in this selection process. Each state was designated as an independent area and five facilities from each state were randomly selected using a table of random numbers.
Description of Questionnaire
A research questionnaire was developed incorporating relevant variables identified in the literature. In addition, questions from a survey by Voss (1991) related to the study of activity therapy programs in substance abuse treatment facilities, and a study by Fazio (1987) concerning the nature of recreation and leisure programs offered to adults with traumatic brain injury, were reviewed and modified for the study questionnaire. The draft questionnaire was reviewed by a panel of experts including practitioners and academicians from therapeutic recreation and rehabilitation disciplines. The study was approved by the Human Subjects Committee at Southern Illinois University at Carbondale.
The activity/recreational therapy staff from each surveyed facility were asked to complete the 20 question survey concerning the characteristics of the facility and therapeutic recreation staff, and types of recreation programs offered by the facility. Questions 1-7 were related to facility and staff, question 8 was related to types of therapeutic recreation or leisure assessment procedures utilized; questions 9-16 were related to the types of therapeutic recreation programs, program length and frequency, and program facilitator. Questions 17-19 were related to therapeutic recreation program goals and Program development, and question 20 solicited additional comments concerning the therapeutic recreation program at each facility.
Each selected facility was mailed a questionnaire and cover letter explaining the purpose of the study and instructions for completing the questionnaire. The respondents were assured of the confidentiality of their individual responses. Following a two week period, all nonrespondents were sent a reminder letter and a second questionnaire.
Following the initial mailing, 21 questionnaires were returned to the sender. Reasons given for their return were change of address, no forwarding address, or forwarding time expired. Twenty-one new agencies were randomly selected from the 1992 National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs. In addition, nine completed questionnaires were unusable because the surveyed agency did not serve adolescents or the survey was inapplicable to the agency. One hundred usable surveys were received for a 40% return rate. Data were coded and analyzed, and descriptive statistics (frequencies, percentages, and mean responses) were calculated to create a profile of the respondents and the programs they represented.
Characteristics of Facilities and Staff
Each survey sent to a facility was addressed to the activity therapist. Job titles of the current position of the individuals responding to the survey included: department head (37%), activity therapy supervisor (5%), recreational therapy supervisor (10%), staff therapist (22%), and other (24%). The "other" (8%) category included drug/alcohol counselors, prevention specialists, directors, etc. About half (49%) of the 100 responding agencies offered an activity/recreational therapy program for adolescents.
Question 2 concerned types of services offered by facilities and multiple responses were possible. The predominant type of services were outpatient (62%), crisis intervention/detox (23%), and residential/therapeutic community (22%). Over 20% of the respondents provided both inpatient and outpatient services. The "other" (8%) facilities offered: aftercare, prevention/early intervention, and school peer groups. Nearly all of the 51 facilities (96%) that had no recreational therapy program provided outpatient services only. Fewer than 1% of the inpatient and residential/therapeutic community services failed to provide recreational therapy services. Reported lengths of stay in treatment included: under 21 days (9%); 21-28 days (17%); 2-3 months (16%); 3-6 months (29%); and 6 or more months (24%).
Respondents were asked to list the total number of activity therapy staff employed and to differentiate between credentialed and non-credentialed staff. These responses were categorized into two groups: full-time staff with a mean of 1.13, and a range from 0 to 55, and part-time staff with a mean of .5 1, and a range of 0 to 25. The number of certified therapeutic recreation specialists (CTRS) employed in responding agencies ranged from 0 to 14, with the mean number of CTRS's at 0.29.
The majority (77.9%) of facilities reported that of recreation/leisure programs are facilitated by activity therapy staff. Multiple responses indicated that joint facilitation of programs by recreation and other staff occurred. Although most planned activities are facilitated by recreation staff members, other staff members responsible for facilitating programs include counselors, therapists, social workers, aides, nursing staff, and volunteers.
The reported procedures which were used within the activity/therapeutic recreation component to assess clients were observation (76%), interview (72%), leisure interest inventory (41%), and institutional/facility designed assessment (39%), standardized TR instruments (7%), and none of the above (9%). Multiple responses indicated that facilities utilized more than one procedure for assessment.
Therapeutic Recreation Programs
Types of programs One of the main foci of this study was to examine the types of therapeutic recreation programs offered within substance abuse treatment facilities for adolescents (see Table I). The program types included: leisure education/counseling (94%), sports/team and individual (88%), community leisure activities (82%), wellness/physical fitness (78%), games (66%), outdoor/adventure (58%), arts & crafts/hobbies (56%), and family leisure activities (41%). Activities offered once a week or less on average were: games, with a range of 0 to 20 times per month; community leisure activities, with a range of 0 to 16 times per month; outdoor/adventure, with a range of 0 to 28 times per month; and family leisure activities, with a range of 0 to 4 times per month. Activities offered an average of almost 3 or 4 times a week included: leisure education/counseling, with a range of 0 to 60 times per month; wellness/physical fitness, with a range of 0 to 32 times per month; sports/team and individual, with a range of 0 to 28 times per month; and arts & crafts/hobbies, with a range of 0 to 20 times per month.
Table I Therapeutic Recreation Programs Offered by Reporting Facilities
Program Type Facilities Sessions/Month Reporting & (%) Leisure Ed. 46 (94%) 15.6 Sports (Team 43 (88%) 11.9 & Individual Community 40 (82%) 4.1 Leisure Activities Wellness/ 38 (78%) 13.9 Physical Fitness Games 33 (66%) 5.0 Outdoor/Adven. 28 (58%) 3.8 Arts, Crafts, Hobby 27 (56%) 11.4 Family Leisure 20 (41%) 2.4 Activities Mean Length of Sessions (Minutes) Leisure Ed. 89 Sports (Team 98 & Individual Community 143 Leisure Activities Wellness/ 76 Physical Fitness Games 77 Outdoor/Adven. 238 Arts, Crafts, Hobby 86 Family Leisure 155 Activities Offered By Offered by University Other Staff of Illinois CTRS Leisure Ed. 14 39 Sports (Team 12 38 & Individual Community 8 35 Leisure Activities Wellness/ 12 33 Physical Fitness Games 10 27 Outdoor/Adven. 10 26 Arts, Crafts, Hobby 8 22 Family Leisure 6 16 Activities n = 49
Length of programs Those activities that lasted under two hours (120 minutes) per session included: wellness/physical fitness, with a range of 0 to 3 hours; games, with a range of 0 to 4 hours; arts & crafts/hobbies, with a range of 0 to 2 hours; leisure education/counseling, with a range of 0 to 7 hours; and sports/team and individual, with a range of 0 to 4 hours. Activities that lasted more than two hours per session included: community leisure activities, with a range of 0 to 8 hours, and outdoor/adventure, with a range of 0 to 8 hours.
Programs Offered by Certified Therapeutic Recreation Specialists Programs that involved a high frequency of CTRS's in implementation encompassed: leisure education/counseling (14), wellness/physical fitness (12), sports/team and individual (12), outdoor/adventure (10) and games (10). Programs that involved a high frequency of other staff in implementation included: leisure education/counseling (39), sports/team and individual (38), community leisure activities (35), wellness/physical fitness (33) and games (27).
Activity Program Goal Areas
The survey listed a variety of goals for therapeutic recreation programs. Each goal was rated on a scale that ranged from "extremely important" (5) to "not important" (1). Improving basic social skills (90%), improving self-esteem/self-efficacy (87%), improving the level of cooperation/trust (84%), increase leisure awareness and develop leisure skills (68%), and increase sense of responsibility (66%) were ranked as very important to extremely important goal areas. Goals that were not considered very important were improving time management skills (30%) and providing opportunities for family leisure (26%) (see Table II).
Table 2 Activity Program Goal Areas
Goal/Importance Extremely Very Important Important Important Improve Wellness 7 (15%) 19 (39%) 16 (33%) Counseling Improve Basic 21 (43%) 23 (47%) 5 (11%) Social Skills Improve Level of 24 (49%) 17 (35%) 6 (13%) Cooperation/Trust Increase Leisure 18 (37%) 15 (31%) 12 (25%) Awareness & Developmental Skills Provide Oppportun. 5 (11%) 7 (15%) 14 (29%) for Family Leisure Improve Time 6 (13%) 8 (17%) 13 (27%) Management Skills Increase Sense of 14 (29%) 18 (37%) 14 (29%) Responsibility Improve Self-esteem/ 33 (68%) 9 (19%) 5 (11%) Self-efficacy Somewhat Not Important Important Improve Wellness 6 (13%) 0 (0%) Counseling Improve Basic 0 (0%) 0 (0%) Social Skills Improve Level of 0 (0%) 0 (0%) Cooperation/Trust Increase Leisure 4 (9%) 0 (0%) Awareness & Developmental Skills Provide Oppportun. 2 (4%) 0 (0%) for Family Leisure Improve Time Management Skills 18 (37%) 3 (7%) Increase Sense of 2 (4%) 0 (0%) Responsibility Improve Self-esteem/ 0 (0%) 0 (0%)
Factors Inhibiting Development of Recreational Therapy
The most frequently cited factors which inhibit the development of a comprehensive therapeutic recreation program were shortage of staff to implement programs (68%), shortage of recreational services (60%). High caseload was also reported by 33% as an inhibiting factor (see Table III).
Table 3 Factors Inhibiting Development of Therapeutic Recreation Services
Factors Number of Percentage Agencies Reporting (n = 49) Shortage of Staff 33 67% Shortage of 29 60% Resources & Space Agency Lacks Awareness 13 27% of Value of Leisure Programs Lack Skills & Knowledge 12 25% to Develop TR Programs Shortage of Funding 29 60% Short Length of Stay 12 25% High Case Load 16 33% No Response 3 7% n = 49
Forms of Assistance Needed to Improve Recreational Therapy
The respondents were asked to check all factors that would be necessary to improve the quality of therapeutic recreation services at their facility. The most important forms of assistance needed are a list of how to initiate activities for adolescent substance abusers (62%), consultation by a CTRS (58%) and in-service training on recreational therapy (49%). Printed resources in leisure education and leisure assessment tools were noted, also. Additional CTRS staff was indicated by 45% of respondents as necessary in order to improve recreational therapy services.
Summary, Conclusion, Discussion, and
Recommendations for Further Research
The purpose of this study was to examine the extent and focus of recreational therapy programs offered within substance abuse treatment facilities for adolescents. Several authors have indicated that therapeutic recreation is an important component in the rehabilitation of individuals who abuse psychoactive chemicals (Kunstler, 1992; Faulkner, 1991). However, the results of this study reveal that not quite half of surveyed facilities (49%) offered a recreational therapy program for adolescents. The therapeutic recreation programs offered the most were leisure education/counseling, sport/team and individual, and community leisure activities. The predominant goals of the therapeutic recreation programs in the surveyed facilities were to improve social skills, self-esteem/self-efficacy and the level of cooperation/trust. Additional comments by respondents indicated that the development and implementation of comprehensive leisure/recreational programs are inhibited by shortages of staff, recreational resources and space, and funding for services.
Facility and Staff Characteristics
Fleisch (1991) asserts that programs designed to serve chronic adolescent substance abusers should be intensive and long enough to ensure that therapeutic changes can be internalized. However, the majority of treatment facilities for adolescents responding to this survey were outpatient, and none offered therapeutic recreation programs. Outpatient treatment is viewed as more cost-effective, and less intrusive in the lives of program participants and is replacing inpatient treatment as the predominant treatment setting. Participants in outpatient programming may be in treatment for a longer period of time (weeks or months) but at a lower level of intensity (1 or 2 hours per week) and diversity of service. Consequently, while the prevalence of outpatient facilities in this sample may have influenced the length of stay upwardly, adolescents in treatment may receive fewer and less comprehensive services.
The modal length of stay among residential facilities was 3-6 months or longer. Fleisch (1991) points out that residential treatment programs usually provide recreation services and often include wilderness experiences to develop cooperative behavior and foster self-esteem. It is significant that these were the two most strongly supported goal areas for all respondents. Both of these areas were listed as important goals for their activity therapy programs. However, outdoor/adventure programs, commonly perceived as popular and typical program offerings, were available in only (58%) of the therapeutic recreation programs and were offered only four times per month on average. These data may reflect the lack of inpatient or residential treatment programs in the survey sample. Outpatient programs may not have the time, staff and facility resources to offer adventure/wilderness programming.
Respondents reported that shortage of staff is a major inhibiting factor in the development and implementation of comprehensive therapeutic recreation programs. Voss (1991) and Kremer, Malkin and Benshoff (1995) found that adult substance abuse treatment facilities employed three to four full-time activity staff, as compared to fewer than a 1/3 full-time equivalent in adolescent treatment facilities. From these findings it would appear that adolescents with substance abuse problems are significantly less likely to receive professionally guided therapeutic recreation services. Rather, it appears that CTRS's may design or consult about therapeutic recreation programs which are then implemented by other staff not specifically trained in therapeutic recreation. Therapeutic recreation programs were implemented by other staff (counselors, social workers, therapists and aides/technicians) almost 50% of the time. Multiple responses indicated that many programs are co-facilitated by more than one staff member.
Moreover, anecdotal comments from respondents revealed a lack of understanding and support for a recreational therapy program at adolescent substance abuse treatment facilities. The most discussed area of concern involved the lack of support and understanding from other staff about the importance of recreational therapy. Cooperation in facilitating programs and being considered an unimportant component in the treatment process was a problem reported by many of the respondents to an open-ended question. Comments included: "the activity therapy staff and the CTRS are not a priority"; "the counselors and staff refuse to support or encourage clients about the importance of leisure activities."; "staff employed for 15 to 20 years have old fashioned views concerning recreation." While facilities and the literature may assert the importance of therapeutic recreation, professional peer recognition and support does not appear to be forthcoming.
Frequently, long-ten-n inpatient programs for adolescents provide services not typically found in adult programs. Adolescent programs usually offer educational programming for their residents, often in response to state mandates. This provision of educational services, along with treatment services, may crowd therapeutic recreation from the schedule of activities in adolescent treatment programs. Paradoxically, students in the public school system receive education in leisure education and wellness programming through health and physical education classes, as well as therapeutic recreation as a support service for students with special needs.
External factors may influence the availability of therapeutic recreation programs and staff in adolescent treatment programs. State licensure regulations and accrediting body standards (Joint Commission on Accreditation of Healthcare Organizations and Commission on Accreditation of Rehabilitation Facilities) may require the provision of therapeutic recreation services. However, state funding authorities and private insurance carriers may balk at funding services which they view as non-essential or non-therapeutic in the more traditional sense. Consequently, facilities are faced with the difficult reality of being required to provide therapeutic recreation services without adequate financial reimbursement. One result of this dilemma may be to keep certified therapeutic recreation staff complements at low levels.
The program offered most frequently by facilities with therapeutic recreation components (94%) was leisure education/counseling. while the most common forms of recreation participation were sports (team and individual) and community leisure activities. These types of recreation participation are diversional and not educational in nature and require fewer staff and less skilled staff. Consequently, these large group activities are cost effective. Additionally, approximately 80% of the surveyed facilities did offer wellness/physical fitness programs. This finding was consistent with Voss (1991) and Kremer (1993).
Goals and Programs Offered
Activity therapy goal areas ranked by facilities as "very important to extremely important" were: improving basic social skills, improving self-esteem/self-efficacy, and improving the level of cooperation/trust. These goals are consistent with the treatment needs of adolescents who have substance abuse problems (Faulkner, 1991; Kunstler, 1992; Sneegas, 1989). Many adolescents may consume their first drink or drug in the context of leisure activities, and ongoing drug and alcohol use may occur during social activities including parties, other social gatherings, or concerts (Aguilar & Munson, 1992). Gang involvement may play a prominent role in substance abuse for some teens (Hanson & Venturelli, 1995). Unfortunately, adolescents with substance abuse problems may not know appropriate leisure activities or social skills devoid of drug or alcohol use. Leisure education/counseling addresses basic social skills (Kunstler, 1992), and Sneegas (1989) argues that social skills, including trust and cooperation, can best be developed through recreation participation. Other recreation activities that improve self-esteem/self-efficacy, problem solving, and the level of cooperation and trust include wilderness challenge programs and games ("New Games" and initiatives). Witman (1987) asserts that completion of adventure activities regarded as challenging will lead to greater confidence and a sense of self-empowerment. However, this type of programming was offered least by facilities with games ranked fifth and wilderness challenge programs ranked sixth of the eight program areas surveyed. Reasons for lack of wilderness programming often involved funding, shortage of space, longer periods of time to implement activities, liability and shortage of staff qualified to initiate such programs. Both games and wilderness activities take substantial external resources, space and time to implement. They are likely to require specialized equipment and specially trained staff, also.
Family leisure programming was offered by fewer than 50% of the respondents on the average of 2.4 times per month, and only 26% of the respondents rated the provision of family leisure opportunities as an "important to very important" goal. From a holistic viewpoint, many of the factors that lead to a adolescent's eventual involvement in psychoactive chemicals can be traced to the lack of trust, communication, and other dysfunctionality that occurs within the family system (Simons & Robertson, 1989) and a number of authors have asserted the importance of family involvement in treatment (Fleisch, 1991; Polcin, 1992). One of the reasons for limited family programming may be low level of involvement by family members concerning their child's treatment. Often adolescents in substance abuse treatment are from dysfunctional families in which one or both parents has a substance abuse problem. These parents may be unwilling to expose or confront their own substance abuse behavior through participation in treatment for their children. Geographic factors or practical realities may play a role in limiting family programming, also. Families who live some distance away from residential facilities may not have the time or economic resources to participate in treatment. For other families, the demands of jobs and raising other children may curtail involvement in either outpatient or inpatient family programming. Nevertheless, Newcomb and Bentler (1988) point out that programs that focus on the developmental needs of adolescent and involve families in treatment are most successful. Malkin, Phillips, and Chumbler (1991) address family leisure issues and suggest the importance of a family leisure education program for adolescents in substance abuse treatment. Interestingly, Voss (1991) also found a low level of both family and outdoor/adventure programming offered in facilities serving adults with substance abuse problems.
Factors Inhibiting Services and Types of Assistance Required
Participants reported a number of factors that inhibited the development of a comprehensive recreational therapy program including shortage of recreational resources and space, shortage of funding for recreational services, and shortage of staff to implement programs. Suggestions were made concerning areas of assistance needed to improve the adequacy of services. The most commonly requested types of assistance were information on how to initiate activities for adolescent substance abusers and the need for periodic consultation with a Certified Therapeutic Recreation Specialist. The respondents also stressed the importance of employment of additional CTRS's and in service training on therapeutic recreation.
One complication related to initiating activities for adolescents is the lack of research related to therapeutic recreation services for adolescent substance abusers. Research supports the enhancement of self-concept and cooperation and trust with delinquent and at risk-youth through participation in areas such as wilderness challenge programs (Witman, 1987) and the development of a comprehensive activity therapy program(Faulkner, 1991) for substance abusers. However, there is little information available related the design and implementation of recreation programs specific to adolescent substance abusers, and little research on the efficacy of such programs.
One contributing factor related to the respondents' reported need for periodic consultation and information on how to initiate programming for adolescents, is that the number of CTR's employed by each agency is less than one full time position. Voss (1991) and Kremer (1993) found that facilities serving adults employed approximately 2 full-time CTRS's. Kunstler (1992) points out that in order to develop and implement a comprehensive therapeutic recreation program, the service of a CTRS may be necessary.
Recommendations For Further Research
The following recommendations for future research are based on the findings and conclusions of this study. Additional research is needed to ascertain the effects or outcomes of specific therapeutic recreation programs for adolescents with substance abuse problems. Little outcome information exists at present. Strategies to examine the status of Certified Therapeutic Recreation Specialists should be considered. In particular, issues of professional recognition, collegial support, and the influence of accreditation standards and funding sources seem to have relevance in the employment of Certified Therapeutic Recreation Specialists in adolescent substance abuse treatment.
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|Author:||Malkin, Marjorie M.|
|Publication:||The Journal of Rehabilitation|
|Date:||Oct 1, 1996|
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