Effectiveness of an Intervention for Improving Intrinsic Motivation among Adolescent Males in a Secure Substance Use Treatment Setting

Abstract

Because intrinsic motivation affects substance use treatment engagement and outcomes, interventions to increase readiness for change are needed. The Treatment Readiness and Induction Program (TRIP) effectively increases intrinsic motivation among youth in community-based residential treatment, but its utility for youth in secure settings is unknown. The current study uses a sequential comparison design to examine the added benefit of TRIP over standard operating practice (SOP) among 125 male adolescents in a juvenile justice treatment facility. Youth receiving TRIP in addition to SOP showed greater increases in problem recognition and desire for help, were three times more likely to want help for emotional problems, and were four times more likely to want individual counseling. Relationships remained after controlling for age and race; however, desire for help was not significant after controlling for substance use severity. Findings document the effectiveness of TRIP for promoting readiness among adolescent males in a secure treatment setting.

Keywords

adolescent substance use treatment treatment readiness motivation problem recognition juvenile justice

Youth involved in the juvenile justice system, the most frequent referral source for youth entering publicly funded substance abuse treatment services, comprise a significant portion of adolescents receiving substance abuse treatment services in the United States (Lipari, Crane, Strashny, & Dean, 2013). These youth also present a unique set of challenges for providers, including behavioral challenges (Becan, Knight, Crawley, Joe, & Flynn, 2015; Breda & Heflinger, 2004; Brorson, Arnevik, Rand-Hendriksen, & Duckert, 2013; Center for Substance Abuse Treatment, 2013; Joe, Knight, Becan, & Flynn, 2014; Marshall & Hser, 2002) and lower internal motivation for change (intrinsic motivation; e.g., problem recognition, desire for help, and treatment readiness; Becan et al., 2015; Breda & Heflinger, 2004; Center for Substance Abuse Treatment, 2013; Joe et al., 2014; Marshall & Hser, 2002; Ryan, Plant, & O’Malley, 1995). Having lower internal motivation places juvenile justice–involved youth at greater risk of poor treatment outcomes regardless of the level of external pressure for treatment (Center for Substance Abuse Treatment, 1999; Curry, Wagner, & Grothaus, 1991; Deci & Ryan, 1985; Diamond et al., 2006; DiClemente, Bellino, & Neavins, 1999; DiClemente & Scott, 1997; Garner, Godley, & Funk, 2008; Garnick et al., 2012; Hiller, Knight, Leukefeld, & Simpson, 2002; Joe et al., 2014; Joe, Simpson, & Broome, 1998; Rogers, Lubman, & Allen, 2008; Tetzlaff et al., 2005). Because the risk of poor treatment outcomes is increased with low internal treatment motivation, interventions that improve internal motivation to change early in the treatment process are especially important.

Youth with legal pressure at treatment entry often have lower problem recognition, desire for help, and readiness for treatment compared with their nonmandated counterparts (i.e., lower internal motivation; Becan et al., 2015; Broome, Joe, & Simpson, 2001; Ryan et al., 1995). Lower personal motivation for change is associated with lower therapeutic engagement (Joe et al., 2014) and is a barrier to desirable treatment outcomes (Curry et al., 1991; Deci & Ryan, 1985; DiClemente et al., 1999). Research shows that while external pressures may provide the impetus for entering and staying in treatment for justice-involved youth (Darbo, 2009; Joe et al., 2014), it is internal motivation for change that is most closely associated with during-treatment markers of recovery and sustained change (Center for Substance Abuse Treatment, 1999; Diamond et al., 2006; DiClemente & Scott, 1997; Garner et al., 2008; Garnick et al., 2012; Hiller et al., 2002; Joe et al., 2014; Joe et al., 1998; Rogers et al., 2008; Tetzlaff et al., 2005). Thus, juvenile justice–involved youth are at greater risk of experiencing poor treatment outcomes.

Risk of poor treatment outcomes is especially notable for youth in secure treatment settings who present with additional treatment challenges compared with those under community supervision. In addition to greater behavioral problems and higher rates of psychiatric need (Brorson et al., 2013; Center for Substance Abuse Treatment, 2013; Lyons, Baerger, Quigley, Erlich, & Griffin, 2001; Robertson, Dill, Husain, & Undesser, 2004), youth in secure settings demonstrate greater resistance to change (Center for Substance Abuse Treatment, 2013) and noncompliance compared with those in nonsecure care settings (Brorson et al., 2013). Because youth in secure settings comprise a sizable number of adolescents in treatment, it is important to examine programming that can boost intrinsic motivation among these youth early in the treatment process (Stein et al., 2006). Thus, this study aims to examine the efficacy of an intervention to improve intrinsic motivation among youth attending substance abuse treatment in secure settings.

One intervention with potential to boost intrinsic motivation among youth in secure settings is the Treatment Readiness and Induction Program (TRIP). TRIP is a cognitive-behavioral intervention designed to improve problem recognition, desire for help, and treatment readiness among adolescents in the first weeks of substance abuse treatment (Bartholomew, Dansereau, Knight, Becan, & Flynn, 2013). Informed by the Integrated Judgement and Decision-Making model (IJDM; Dansereau, Knight, & Flynn, 2013), TRIP builds wisdom and expertise through the application of analytically created schemas (ACSs, or structured guide maps) to real-life scenarios. Activities employ visual-spatial techniques (known as Mapping-Enhanced Counseling; Dansereau & Simpson, 2009) to depict complex concepts and events and help participants better understand their own behavioral sequences (e.g., precursors to or consequences of substance use (SU); see D. K. Knight, Dansereau, Becan, Rowan, & Flynn, 2015, for more detail). Participants also explore options and potential consequences of choices by applying ACSs to fictitious and personal problems. With practice, these strategies become internalized and subsequently available as part of experiential or “automatic” processing (Dansereau et al., 2013).

Prior research has documented TRIP’s effectiveness among youth in community treatment settings, many of whom are court-referred (59% juvenile justice–involved; Becan et al., 2015). Compared with youth receiving only standard operating practice (SOP), youth receiving SOP plus TRIP show greater improvement in treatment motivation. When controlling for extrinsic motivation (i.e., youth report that treatment is legally mandated), TRIP clients report better postintervention problem recognition, decision making, and engagement compared with SOP-only clients (D. K. Knight et al., 2016). While effective for promoting readiness among youth in community-based treatment, its impact on youth in secure treatment settings is unknown. The purpose of this study is to examine the utility of TRIP in promoting intrinsic motivation among youth in juvenile justice secure care settings. Youth who receive TRIP in addition to SOP are expected to exhibit greater improvement compared with youth receiving SOP only.

Method

Data were collected from youth in a juvenile minimum security facility located in a Midwestern state. The facility offered residential SU treatment operated by an independent provider contracted by the state justice agency (capacity of 50 males). All protocols were approved by both the university and participating agency institutional review boards.

Design

Because clients receiving only SOP would have the potential for unintentional exposure to TRIP elements, a sequential comparison design was used. In the first phase, the agency served as its own control, implementing assessments while engaging in SOP. In the second phase (after 8 months), clinical staff were trained on the TRIP curriculum and implementation with clients began. Youth admitted after assessments began and before TRIP was implemented formed the SOP group. Youth admitted after TRIP began received SOP and TRIP (TRIP group).

Sample

A total of 170 youths were admitted to the substance abuse program between October 2012 and February 2015. Of these, 108 entered during SOP and 62 during TRIP. However, 10 SOP youth were potentially exposed to TRIP (admitted during the 1 month between training and implementation) and were omitted. In addition, 20 SOP youth did not have Time 2 follow-up data and therefore were not available for analysis. Of the 62 TRIP youth, nine did not receive a sufficient dose of the intervention (at least four TRIP sessions) and an additional six did not have Time 2 follow-up data. Missing follow-up data were generally due to rapid or unscheduled discharge. The final study sample was 125, with 78 in SOP and 47 in TRIP (see Figure 1).

Figure 1:

Participant Enrollment in SOP and TRIP Conditions

The Treatment Readiness and Induction Program (TRIP)

The TRIP curriculum is an eight-session, manual-based intervention intended for implementation within the first weeks of treatment (Bartholomew et al., 2013). Ninety-minute sessions are typically delivered once weekly for 8 weeks or twice weekly for 4 weeks in closed or open (youth join as they enter treatment) group settings. Sessions are organized around four themes: Mapping (using graphical approaches to enhance decision making), Nudges (identifying cues and using them to shape behavior), Downward Spiral (playing an experiential board game to understand consequences of continued drug use), and Work It (applying decision-making schemas to identify, evaluate, and select options; see Becan et al., 2015; D. K. Knight et al., 2015). Each session begins with an interactive warm-up that introduces a topic related to decision making (e.g., jumping to conclusions, recognizing how emotions affect decisions). Counselors then introduce the strategy emphasized in the session (e.g., using maps to sort out complex problems, identifying options for how to respond) and participants apply those strategies to fictitious scenarios and personal situations.

Standard Operating Practice (SOP)

In addition to educational services (which comprised most of the daily schedule), SOP included two counseling-based group sessions daily, 1 hr in the afternoon after school and 1 hr in the evening. Group session topics included drug education, responsible behavior, anger management, handling difficult feelings, and team building, among others. Counselors also met with youth individually each week to address their specific therapeutic needs.

Procedures

At project start, agency staff were trained on administering and interpreting youth assessments. The Texas Christian University (TCU) Adolescent Screening and Assessment Package (D. K. Knight, Becan, Landrum, Joe, & Flynn, 2014) was administered to all admitted youth by agency staff via scannable paper and pencil forms at intake (Time 1) and 30 to 45 days later (Time 2; mean days = 43.4 [SD = 9.2]). Unique identification numbers were assigned to newly enrolled clients and used to link responses across forms and over time. A staff coordinator was available to assist youth as they independently responded to assessment items.

After 8 months, staff were trained on the TRIP curriculum content (Bartholomew et al., 2013) during a 2-day workshop. Topics included an overview of the purpose of the curriculum and session content, and training on Mapping-Enhanced Counseling (which forms the basis of TRIP; Dansereau & Simpson, 2009), as well as facilitating session activities, utilizing peer mentors, and implementing the intervention at their agency. Participants received continuing education credits, reimbursement for travel costs, and all materials needed to implement TRIP (e.g., paper and electronic copies of the manual, the Downward Spiral game, items needed for session activities). Upon training completion, staff conducted TRIP groups with youth and trained additional staff to ensure continued implementation in the event of staff turnover. Support for TRIP implementation was provided upon request (see D. K. Knight et al., 2016).

Following staff training, the TRIP intervention was incorporated into existing practice as two 90-min sessions administered each week (for 4 weeks) by two clinicians (both White, Certified Alcohol and Other Drug Counselors [CADC], one male). Youth were enrolled in a TRIP group immediately upon program entry after assessments were completed. Two TRIP groups were run simultaneously with start dates approximately 2 weeks apart to reduce wait time for entry into the closed group. The agency implemented TRIP groups on a rolling basis (repeating the cycle of eight sessions in sequence) over an 11-month period, completing 13 intervention cycles. Fidelity checklists completed by facilitators after each session indicated that 98% of the TRIP content was covered in sessions, discussion occurred in 99% of sessions, and Mapping-Enhanced Counseling was utilized in 97% of sessions. Clinician report of adherence to the TRIP protocol was corroborated by research team observation during a scheduled site visit.

Measures

During-Treatment Outcomes

Treatment motivation was assessed using youth versions of the treatment motivation scales: Problem Recognition (PR; α = .93), Desire for Help (DH; α = .79), and Treatment Readiness (TR; α = .67). These were measured at intake (Time 1) and during treatment (Time 2). Each of the 36 items was rated using a 5-point Likert-type scale (1 = disagree strongly, 2 = disagree, 3 = uncertain, 4 = agree, 5 = agree strongly). PR comprised 10 items (e.g., “Your drug use is a problem for you”), DH comprised six items (e.g., “You need help dealing with your drug use”), and TR comprised eight items (e.g., “This treatment gives you a chance to solve your drug problems”). In addition, five items assessing treatment needs (e.g., “You need help with your emotional troubles,” “individual counseling,” “education/job training,”, “medical care”) were dichotomized into “agreeing that it was a need” (4 or 5) versus “not agreeing it was a need” (1, 2, or 3). The summed total of these five dichotomous variables was also analyzed as a separate outcome measure (Treatment Needs, TN; α = .60). Treatment engagement was assessed at Time 2 using youth versions of the engagement scales. Participation comprised 11 items (“You are willing to talk about your feelings during counseling”; α = .90), satisfaction comprised six items (“You are satisfied with this program”; α = .78), counselor rapport comprised 12 items (“Your counselor is easy to talk to”; α = .93), and peer support comprised five items (“Other clients at this program care about you and your problems”; α = .71).

Covariates

To control for potential Time 1 differences and to rule out the impact of anticipated relationships between background characteristics (age, race, and SU) and motivation, demographic and SU variables were examined as covariates. Youth in juvenile secure care settings tend to be older than those in community-based settings, and older youth report greater motivation for change (D. K. Knight et al., 2014). Black youth are overrepresented in juvenile justice settings and detention (Hsia, Bridges, & McHale, 2004; Nicholson-Crotty, Birchmeier, & Valentine, 2009). Furthermore, higher scores on SU Severity measures are related to greater motivation to change (Breda & Heflinger, 2004; Slesnick et al., 2009).

Covariates included age, race–ethnicity, and SU Severity and were collected at Time 1. Race was categorized as Hispanic, African American, White, or Other Race. SU Severity was obtained from the TCU Drug Screen II (D. K. Knight, Blue, Flynn, & Knight, in press; K. Knight, Simpson, & Hiller, 2002). The first 12 items parallel substance abuse/dependence diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). Questions include “Did you use larger amounts of drugs or use them for a longer time than you planned or intended?” If three or more items were endorsed, youth were classified as dependent, indicating relatively severe substance-related problems.

Participant Acceptability of TRIP

Youth participating in TRIP sessions were asked to provide feedback on session content at Time 2. Items were rated on a Likert-type scale ranging from 1 (disagree strongly) to 5 (agree strongly). Examples include the following: “TRIP sessions helped me understand myself better,” “TRIP sessions helped me want to make positive changes in my life,” “TRIP sessions kept my attention,” “TRIP sessions helped me with my problems,” and “I felt comfortable speaking up during TRIP sessions.”

Analysis Plan

The hypothesis was tested using a general linear model analysis (SAS PROC GLM), with each of four Time 2 treatment motivation measures serving as dependent variables (PR, DH, TR, and TN). Each of the five dichotomous Time 2 TN outcomes was analyzed using logistic regression (SAS PROC Logistic). For all outcome measures, three models were computed. Model 1 examined the significance of the intervention (TRIP vs. SOP) on the Time 2 measure of each outcome, with the corresponding Time 1 measure for that outcome as the covariate. Model 2 expanded Model 1 by adding demographics (age and race) as additional covariates. Model 3 furthered the examination of the effectiveness of the intervention by including SU Severity as an additional covariate.

Results

Being in the SOP or TRIP was not significantly related to age (r = .01, p = .90), race, χ²(3) = 4.43, p = .22, or education, χ²(2) = 2.63, p = .27 (see Table 1). However, twice as many individuals had a score above the threshold for drug dependence in the TRIP group (38.6%) compared with the SOP group (18.9%), χ²(1) = 5.54, p = .02. Nearly 45% of the two treatment samples reported using any illegal drug on at least a weekly basis in the 12 months prior to this treatment episode, with 41% (n = 51) reporting daily or weekly use of marijuana and 18% (n = 22) alcohol. The treatment groups did not differ significantly (p > .05).

Table 1:

Background Variables by Intervention Group

Measure	Total (N = 125)	TRIP (n = 47)	SOP (n = 78)
Demographics
Mean age (SD)	16.3 (1.1)	16.4 (1.0)	16.3 (1.2)
Race, n (%)
Hispanic	15 (12%)	2 (4%)	13 (17%)
African American	42 (34%)	18 (38%)	24 (31%)
White	52 (41%)	21 (45%)	31 (39%)
Other race	16 (13%)	6 (13%)	10 (13%)
Education, n (%)
Less than 9	40 (32%)	19 (40%)	21 (27%)
9-11	74 (59%)	25 (54%)	49 (63%)
12 or GED	11 (9%)	3 (6%)	8 (10%)
Mean substance use severity (SD)	10.5 (2.2)	11.1 (2.4)	10.1 (2.0)
Substance use dependence (% above threshold)	31 (26%)	17 (39%)	14 (19%)
At least weekly drug use, n (%)
Alcohol	22 (18%)	9 (19%)	13 (17%)
Marijuana	51 (41%)	24 (51%)	27 (35%)
Methamphetamines	5 (4%)	2 (4%)	3 (4%)
Speedball	2 (2%)	1 (2%)	1 (1%)
Crack cocaine	2 (2%)	0 (0%)	2 (3%)
Cocaine (by itself)	4 (3%)	2 (4%)	2 (3%)
Heroin (by itself)	2 (2%)	0 (0%)	2 (3%)
Other opiates	3 (2%)	1 (2%)	2 (3%)
Downers	2 (2%)	1 (2%)	1 (1%)
Other	10 (8%)	6 (13%)	4 (5%)
Previous juvenile detention, n (%)	65 (52%)	24 (51%)	40 (52%)
Previous SU treatment, n (%)	20 (16%)	6 (13%)	14 (18%)

Note. Demographic data from the TCU ADOL RSKFORMs A and B; substance use data from the TCU Drug Screen II. TCU = Texas Christian University; TRIP = Treatment Readiness and Induction Program; SOP = standard operating practice; SU = substance use; GED = general education diploma.

Acceptability of TRIP

Clinicians found the TRIP curriculum helpful to maintain focus, support concept/skill development on visual mapping techniques, and appropriate for justice-involved youth in addressing risky decision making around SU. Counselors cited the utility of mapping to facilitate brainstorming on responsible behavior and otherwise sensitive topics such as sexual health, trauma, and grieving and for addressing negative self-talk in anger management sessions. Participants also endorsed TRIP, with 59% reporting TRIP sessions were enjoyable; over 60% reporting better personal understanding, focused attention, help with problems, and comfort speaking up; and over 70% reporting TRIP sessions made them want to make positive changes in their lives.

Model 1: Effects of Intervention With Time 1 as a Covariate

In general, youth in both conditions showed improvement over time (see Figure 2 and Table 2). However, results documented significantly higher means at Time 2 on problem recognition and desire for help for youth in TRIP compared with SOP (see Table 3). Results for dichotomous outcomes indicated that larger percentages of youth in TRIP reported needing help for emotional problems and wanting individual counseling (see Table 4). The corresponding Time 1 measure was a significant covariate in every analysis with the exception of Medical Care Services.

Figure 2:

Change in Motivation Scales Over Time

Table 2:

Means (SD) and Frequencies (%) Indicating Change in Identification of Treatment Needs Over Time by Intervention Group

	Total (N = 125)		TRIP (n = 47)		SOP (n = 78)
Measure	Time 1	Time 2	Time 1	Time 2	Time 1	Time 2
Treatment needs index	1.00 (1.09)	1.32 (1.33)	1.06 (1.09)	1.57 (1.56)	.96 (1.08)	1.17 (1.16)
Emotional problems	16 (13%)	29 (23%)	6 (13%)	16 (34%)	10 (13%)	13 (17%)
Individual counseling	18 (14%)	25 (20%)	7 (15%)	15 (32%)	11 (14%)	10 (13%)
Education/job training	70 (56%)	75 (60%)	25 (53%)	23 (49%)	45 (57%)	52 (67%)
Group counseling	14 (11%)	22 (18%)	9 (19%)	12 (26%)	5 (6%)	10 (13%)
Medical care services	8 (7%)	14 (11%)	3 (6%)	8 (17%)	5 (6%)	6 (8%)

Note. Data from the TCU ADOL MOTFORM; treatment needs index is the average of the sum of five items: emotional problems, individual counseling, education/job training, group counseling, and medical care services. TCU = Texas Christian University; TRIP = Treatment Readiness and Induction Program; SOP = standard operating practice.

Table 3:

Intervention Effects on Motivation for Treatment (F Statistics)

	Outcomes (Time 2)
Analysis	Problem Recognition (PR)	Desire for Help (DH)	Treatment Readiness (TR)	Treatment Needs (TN)
Model 1: (N = 125), F(1, 118)
TRIP vs SOP	8.55**	4.11*	2.44	2.58
Time 1	87.49***	101.07***	60.86***	29.31***
Model 2: Including covariates (N = 125), F(1, 118)
TRIP vs SOP	7.28**	4.23*	1.45	2.30
Time 1	76.88***	95.95***	56.23***	27.91***
Age	.50	2.74	1.10	.38
Race (four groups)	.61	.31	1.44	.10
Model 3: Including covariates and substance use severity (N = 118), F(1, 110)
TRIP vs SOP	7.39**	2.76	1.09	.73
Time 1	40.49***	66.08***	45.75***	21.17***
Age	.62	2.74	1.17	.40
Race (four groups)	.90	.35	1.84	.04
Substance use severity	1.50	1.34	.24	2.50

Note. Data from TCU ADOL RSKFORMs A and B, TCU Drug Screen II, and TCU ADOL MOTFORM. TCU = Texas Christian University; TRIP = Treatment Readiness and Induction Program; SOP = standard operating practice.

p < .05. **p < .01. ***p < .001.

Table 4:

Intervention Effects on Specific Treatment Needs (Chi-Square Statistics)^a

	Outcomes (Time 2)
Analysis	Emotional problems	Individual counseling	Education/job training	Group counseling	Medical care
Model 1: (N = 125)
TRIP vs SOP	4.59*	6.67**	3.40	.24	1.69
Time 1	13.76***	10.42**	6.01*	19.54***	.04
Model 2: Including covariates (N = 125)
TRIP vs SOP	4.74*	7.47**	3.01	.26	1.23
Odds ratio [95% CI]	2.97 [1.12, 7.92]	4.43 [1.52, 12.90]	.50 [.23, 1.09]	1.35 [.43, 4.26]	1.95 [.60, 6.34]
Time 1	14.18***	12.37***	6.38*	17.16***	.00
Age	.19	.11	.92	.001	.00
Race (four groups)	2.06	3.87	.85	.88	1.78
Model 3: Including covariates and substance use severity (N = 118)
TRIP vs SOP	4.63*	5.71*	3.43	.01	.20
Odds ratio [95% CI]	2.98 [1.10, 8.03]	3.81 [1.27, 11.44]	.46 [.20, 1.05]	.93 [.26, 3.26]	1.34 [.38, 4.74]
Time 1	11.45**	8.15**	5.61*	10.75***	.11
Age	.38	.29	.72	.07	.01
Race (four groups)	1.52	2.78	.91	.26	1.53
Substance use severity	.47	1.72	.00	4.83*	2.92

χ²(1) for all independent variables except Race, χ²(3).

p < .05. **p < .01. ***p < .001.

Model 2: Effects of Intervention With Time 1 and Demographics as Covariates

Model 2 results were similar to Model 1 in that the intervention remained a significant factor in the analysis of problem recognition, desire for help, needing help for emotional problems, and wanting individual counseling. For the latter two, individuals in TRIP were approximately three times more likely to want help with emotional problems and four times more likely to want individual counseling than individuals treated in SOP only. Similarly, the corresponding Time 1 measure was a significant predictor of its Time 2 measure with the exception of Medical Care Services. None of the demographic variables were significant.

Model 3: Effects of Intervention With Time 1, Demographics, and SU Severity as Covariates

Model 3 results supported the significant intervention effect on problem recognition, wanting help for emotional problems, and wanting individual counseling even after controlling for these covariates. However, the intervention effect on DH was no longer significant at the p < .05 level. The addition of SU Severity as a covariate statistically adjusts for this difference. Further examination of the relationship among variables within groups indicated that for SOP, SU Severity was significantly correlated with desire for help at both Time 1 (r = .47, p < .001) and Time 2 (r = .47, p < .001); however, for TRIP, the correlation of SU Severity was significantly correlated with desire for help at Time 1 (r = .35, p = .018), but not at Time 2 (r = .18, p = .238). As in the previous models, the corresponding Time 1 measure was a significant predictor of its Time 2 measure with the exception of Medical Care Services. Demographic measures and SU Severity were generally not significant predictors of the Time 2 measures; however, SU Severity was significant in the prediction of wanting Group Counseling.

Relationship Between Motivation and During-Treatment Progress

While not a primary aim of the study, it is useful to document the degree to which gains in motivation correspond to proximal outcome measures such as during-treatment engagement. Among youth in the TRIP group, desire for help was related to treatment participation (r = .40, p = .005), counselor rapport (r = .37, p = .01), treatment satisfaction (r = .51, p < .001), and peer support (r = .42, p = .003) at Time 2. Among youth in SOP only, motivation was not related to engagement.

Discussion

Findings document the effectiveness of TRIP for promoting motivation for change among adolescent males in a secure SU treatment setting. While improvement in all domains was observed for youth in both conditions, those receiving TRIP in addition to SOP reported significantly higher problem recognition and desire for help at Time 2 compared with youth receiving SOP only. Furthermore, TRIP clients were three times more likely to want help with emotional problems and four times more likely to want individual counseling. These benefits of TRIP remained significant after controlling for baseline measures of each construct and youth demographics. Strengthening motivation through TRIP activities appears to promote engagement, as evidenced by the significant positive relationship between desire for help and during-treatment outcomes for youth in TRIP. These findings corroborate results from other studies documenting motivation as a predictor of engagement (Joe et al., 2014) and the utility of TRIP in promoting engagement (D. K. Knight et al., 2016).

Because SU can affect thinking patterns and self-control (Shane, Jasiukaitis, & Green, 2003), accounting for SU severity is important in determining TRIP effectiveness. Problem recognition and identification of treatment needs (help with emotional problems, individual counseling) remained higher among TRIP clients when SU Severity was included in the model. This is noteworthy because the TRIP group encompassed a higher proportion of youth with severe SU problems. However, the intervention’s effect on desire for help was no longer significant (p < .10) when controlling for SU Severity. Two potential reasons could explain this lack of significance. First, this may be due to a 5.6% sample loss (due to missing SU Severity). Without adjusting for severity, youth in TRIP had a higher desire for help at Time 2 compared with youth in SOP only. Second, the problem recognition and desire for help scales represent fundamentally different constructs. Problem recognition assesses whether drug use is interfering with specific areas in one’s life (e.g., family, school attendance), whereas desire for help assesses whether the individual is “tired of the problems” caused by drug use and is willing to make personal changes. According to the Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992), a period of contemplation (problem recognition) precedes preparation (desire for help) and action (readiness for treatment; see also Hiller et al., 2002; Simpson & Joe, 1993). Indeed, there is evidence among community-based adolescent samples that TRIP indirectly affects desire for help and treatment readiness through its impact on problem recognition (Becan et al., 2015). Perhaps TRIP is effective in promoting problem recognition for all youth, but is most effective in promoting later stages of change among youth who already have some awareness of problems. Further research is needed to fully explore this potential explanation.

The TRIP curriculum is founded on the principles of Mapping-Enhanced Counseling (Dansereau & Simpson, 2009) and the use of analytic schemas to promote introspection and decision making (Dansereau et al., 2013). Prior research documents that this interactive and visual approach increases self-awareness (with regard to personal thinking strategies), helps with personal decision making through the use of specific strategies (e.g., writing or drawing things out), promotes a positive approach toward problems, and advances the recognition of consequences of drug use (D. K. Knight et al., 2015). Males in particular show greater gains in strategy use and recognizing drug use consequences compared with females. The current study provides corroborating evidence and suggests that TRIP may be particularly well suited for young men in secure treatment settings. The high degree of fidelity in curriculum implementation and positive reactions from counselors and participants also supports its appropriateness for justice-involved males. Specifically, counselors reported that TRIP mapping content and activities were useful for maintaining client focus, developing concepts/skills, and identifying and addressing risky decisions around SU.

While results document the utility of TRIP for promoting treatment motivation, limitations should be noted. The sample is drawn from one juvenile justice facility located in the US Midwest region which limits generalizability to other settings and populations. The use of a sequential comparison design where the agency served as its own control promoted equivalence in contextual factors between the two study conditions (e.g., staffing, services offered), but naturally occurring clientele or programmatic changes could have resulted in history effects. For example, findings indicated a change in the proportion of youth with higher drug use severity over time, with clients in the TRIP condition having higher severity at intake. While severity was accounted for in analyses, there could be other unidentified factors that influence results. Furthermore, measurement of treatment readiness may be challenging for individuals in secure care settings because contextual factors may shape how they respond. For instance, many youth who are detained do not fully embrace their judicial mandates and may wish to leave. This perspective may influence how they interpret and respond to the items, “you need to be in treatment now” and “you are ready to leave this treatment program.” Future research should examine how legal mandates and resistance interact with baseline intrinsic motivation to predict participation in motivational enhancement interventions. Finally, this study focuses on proximal outcomes early in treatment. While the role of motivation in treatment engagement and long-term outcomes is well documented (Joe et al., 2014) and early induction strategies are warranted (DiClemente, Garay, & Gemmell, 2008), future studies are needed to determine whether these improvements in the first weeks of treatment as a result of TRIP translate to long-term, sustained outcomes.

Although prior research documents the utility of external pressure for increasing treatment retention (Darbo, 2009; Fagan, 1999; Mueller & Wyman, 1997; Sindelar & Fiellin, 2001), extrinsic motivation alone is insufficient to facilitate long-term results. Intrinsic motivation is key to engagement and personal recovery, yet it is often lower among individuals mandated to treatment (Broome et al., 2001; Joe et al., 2014). Because clients must be open to change for treatment intervention efforts to be fruitful, intentional efforts to enhance intrinsic motivation in the early weeks of treatment are crucial. Findings from this study suggest that the eight-session TRIP curriculum provides added value beyond standard SU treatment practices for adolescent males in secure settings.

Footnotes

Authors’ Note:

The authors would like to acknowledge the contributions of administrators and clinical staff at the Illinois Department of Juvenile Justice and participating agencies who worked diligently to ensure that assessment and curriculum protocols were implemented with fidelity. This work was funded by the National Institute on Drug Abuse (NIDA; Grant R01DA013093). The interpretations and conclusions, however, do not necessarily represent the position of the NIDA, National Institutes of Health, or Department of Health and Human Services.

Danica K. Knight, PhD, is a senior research scientist at Texas Christian University’s Institute of Behavioral Research. She conducts large-scale research projects designed to further understanding of substance abuse treatment processes and promote best practices. Her publications focus on the importance of social and cognitive factors for clients in treatment, factors affecting adolescent recovery from substance use, and organizational features associated with service provision and implementation of new practices.

George W. Joe, EdD, is a senior research scientist at Texas Christian University’s Institute of Behavioral Research in Fort Worth. His research has focused on the components of the treatment process, evaluation models for treatment effectiveness and associated relationships of social and organizational factors in those models, etiology of drug abuse, and statistical methodology.

Jennifer E. Becan, PhD, is an associate research scientist at Texas Christian University’s Institute of Behavioral Research and the Karyn Purvis Institute of Child Development. She conducts large-scale research projects designed to further understanding of effectiveness of implementation strategies to improve adoption and quality of substance use and trauma-informed services.

Rachel D. Crawley, PhD, is an associate research scientist at the Karyn Purvis Institute of Child Development at Texas Christian University. She coordinates training evaluation and conducts research projects designed to examine the effectiveness and use of Trust-Based Relational Intervention^® (TBRI^®), an attachment-based therapeutic approach for helping children recover from the impact of trauma.

Sarah E. Theisen, MS, is a senior research analyst at Denver Public Schools. She leads all major student outcome releases and manages the external research review board. She ensures all releases provide clear, relevant, accurate, timely, and actionable information to district and school leaders in concise and impactful manner.

Patrick M. Flynn, PhD, is professor of psychology and director of the Institute of Behavioral Research at Texas Christian University where he holds the Saul B. Sells Chair of Psychology. His research focuses on the effectiveness and benefits of treatment and includes clinical assessment, questionnaire development, and multisite clinical trials and survey research. He is a fellow in the American Educational Research Association and in several divisions of the American Psychological Association.

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