Promoting change in secure settings : adaptation and evaluation of the adolescent community reinforcement

Abstract

BackgroundAdolescents in secure care constitute one of the most vulnerable groups in society, commonly contending with intersecting adversities, substance use, and involvement in severe crime. Also, they are in a setting where personal freedom is restricted. Despite the complexity of their needs and the high risk of continuing a destructive pathway into adulthood, few interventions have been rigorously evaluated or tailored for delivery in closed secure settings in Sweden. The Adolescent Community Reinforcement Approach (A-CRA), originally developed for outpatient services, has demonstrated effectiveness in promoting abstinence and prosocial behaviour in community contexts, but had not previously been tested within secure care.AimsThe main objective of this thesis was to examine A-CRA in secure settings from multiple perspectives: adolescents' and therapists' experiences, feasibility in the secure environment, potential processes of change it engages, and what outcomes it yields in comparison with treatment-as-usual. More specifically, the effectiveness of A-CRA on social, emotional, and behavioural problems, substance use, and prosocial behaviour.MethodsFour interlinked studies were conducted:I. Therapists' experiences of conducting A-CRA in secure care were explored and specifically how treatments were perceived, how A-CRA was adapted to the secure setting, and potential facilitators and barriers in delivery. Interviews were analysed using qualitative content analysis with an inductive approach (N = 7).II. A potential novel change process for A-CRA in secure care was investigated through a mixed-methods study of adolescents' goal-talk. First, content analysis with a deductive approach was used to develop a coding manual using a Relational Frame Theory framework, and second, the association between the coded goal talk and change in A-CRA was investigated (N = 12).III. Feasibility, acceptability and preliminary treatment effects was investigated through a mixed methods randomised trial comparing A-CRA as an addition to treatment-as-usual (TAU) with TAU alone and investigating adolescents' experiences of undergoing A-CRA in secure care through interviews (N = 42).IV. Randomised controlled trial evaluating the effectiveness of A-CRA in secure care by comparing A-CRA + treatment-as-usual (TAU) with TAU alone (N = 84).ResultsI. Therapists reported that A-CRA was useful in secure care with only minor adaptations. The programme’s flexibility and scope for individual tailoring were viewed as enhancing engagement, and a strong therapeutic alliance was considered essential to success.II. Among adolescents receiving A-CRA, goal-related verbal behaviour (goal-talk) was feasible to identify, code, and analyse. Appetitive goal-talk showed strong associations with reduced substance use and with movement towards personally endorsed values.III. A-CRA proved feasible and acceptable in secure care, with a 77% completion rate. Adolescents generally described positive treatment experiences. Registry indicators suggested lower relapse to substance use in A-CRA + TAU (54%) than in TAU (92%), whereas rates of serious norm-violating behaviour were similar across conditions. Recruitment and randomisation procedures were workable, however, administering paper self-reports led to substantial missing data.IV. In the definitive trial, both A-CRA + TAU and TAU yielded improvements in emotional, social, and behavioural problems, alongside gains in prosocial behaviour. Differences between groups were not clearly distinguishable in the full sample. In the completer sub-sample, adolescents receiving A-CRA + TAU showed greater improvement in emotional symptoms and conduct problems than those receiving TAU alone.ConclusionsA-CRA can be delivered in secure care with minor adaptations and is perceived as acceptable and helpful to adolescents and therapists. Notably, the flexibility of A-CRA, allowing therapists to tailor sessions to adolescents' specific goals and needs, was seen by therapists and adolescents to increase engagement, which is often difficult to maintain in compulsory secure care. Measuring goal-talk is a promising approach to capturing proximal change processes in this context. Across studies, A-CRA achieved effects comparable to those typically observed in outpatient delivery, however, the evidence does not indicate a clear advantage over other CBT-based treatments currently provided in secure care.ImplicationsPolicy and service implications include that A-CRA is perceived as helpful by therapists and adolescents and that treatment can be delivered as intended with smaller adaptations. Furthermore, A-CRA decreases problem behaviours in secure settings. Lastly, that flexibility and focus on individual goals as part of treatment seems to foster engagement and motivation for change towards prosocial pathways for adolescents within compulsory, secure care, where personal freedom is already very restricted.List of scientific papersI. Mälarstig, I., Tyrberg, M. J., Lundgren, T., & Alfonsson, S. (2023). Experiences of conducting a substance use disorder treatment, A-CRA, in compulsory institutional care for youth-The challenge of promoting openness in a closed, temporary setting. Children and youth services review, 148, 106850. https://doi.org/10.1016/j.childyouth.2023.106850II. Mälarstig, I., Törneke, N., Lundgren, T., Alfonsson, S., & Tyrberg, M. J. (2025). "Finding your values is important. You only die once."- Analysing goal-talk in incarcerated adolescents struggling with substance use from a Relational Frame Theory perspective. Journal of Contextual Behavioral Science, 100947. https://doi.org/10.1016/j.jcbs.2025.100947III. Mälarstig, I., Spännargård, Å., Garke, M. Å., Tyrberg, M., Lundgren, T., & Alfonsson, S. (2025). Adolescent Community Reinforcement Approach in Secure care for Adolescents with Substance Use and Severe Norm-Violating behavior: A Randomised Feasibility Trial. [Submitted]IV. Mälarstig, I., Spännargård, Å., Garke, M. Å., Sahlin, H., Lundgren, T., & Alfonsson, S. (2025). The effectiveness of the Adolescent Community Reinforcement Approach in secure care for adolescents with substance use and severe norm-violating behavior: A randomised controlled trial. [Manuscript]</p