Criminology Therapy and Comparative International Journal of Offender

International Journal of Offender Therapy and Comparative Criminology http://ijo.sagepub.com/

Measuring Treatment Motivation in Secure Juvenile Facilities G. H. P. Van der Helm, I. B. Wissink, T. De Jongh and G. J. J. M. Stams Int J Offender Ther Comp Criminol published online 23 May 2012 DOI: 10.1177/0306624X12443798 The online version of this article can be found at: http://ijo.sagepub.com/content/early/2012/05/22/0306624X12443798

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IJOXXX10.1177/0306624X12443798Van der Helm et al.International Journal of Offender Therapy and Comparative Criminology

Measuring Treatment Motivation in Secure Juvenile Facilities

International Journal of Offender Therapy and Comparative Criminology XX(X) 1–13 © The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0306624X12443798 http://ijo.sagepub.com

G. H. P. Van der Helm1, I. B. Wissink2, T. De Jongh3, and G. J. J. M. Stams2

Abstract The present study examined the validity and reliability of the Adolescent Treatment Motivation Questionnaire (ATMQ) in a sample of 264 adolescents in Dutch secure juvenile facilities. Confirmatory factor analysis of a single-factor model of “treatment motivation” showed a close fit to the data, indicating construct validity of the ATMQ. Concurrent validity was supported by significant relations between treatment motivation and living group climate. Internal consistency reliability in terms of Cronbach’s alpha was good (.84). The ATMQ proved to be insensitive to the tendency to provide socially acceptable or desirable answers, which supports discriminant validity, and was unrelated to sex, age, and self-reported aggression of the adolescents. The ATMQ is a parsimonious instrument (11 items) enabling future research on treatment motivation in secure juvenile facilities. Keywords treatment motivation, validity and reliability, adolescence, living group climate, secure juvenile facilities Treatment in secure juvenile institutions, including youth correctional facilities, is still considered a “black box” that has not been opened yet (Axford, Little, Morpeth, & Weyts, 2005; Gendreau, Goggin, French, & Smith, 2006). Recent meta-analyses, however, have shown that (secure) institutional youth care can be effective for a range

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Leiden University of Applied Sciences, Netherlands University of Amsterdam, Netherlands 3 Amsterbaken Youth Correctional Centre (Spirit Group), Amsterdam, Netherlands 2

Corresponding Author: G. H. P. Van der Helm, Leiden University of Applied Sciences, Netherlands, Zernickedreef 11, P.O. Box 2300 AJ Leiden, Netherlands Email: [email protected]


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International Journal of Offender Therapy and Comparative Criminology XX(X)

of behavioral and developmental outcomes, in particular when treatment is evidence based (De Swart et al., 2011) and the approach is therapeutic instead of coercive (Lipsey, 2009; Parhar, Wormith, Derkzen, & Beauregard, 2008). Environmental characteristics, such as living group climate (Van der Helm, Stams, & Van der Laan, 2011), and individual inmate characteristics, such as treatment motivation, that may affect therapeutic change are still underresearched, which is partly due to a lack of valid and reliable instruments to assess these characteristics (Marshall & Burton, 2010; Van der Helm, 2011). Treatment motivation seems important for recruitment, engagement, and retention in compulsory treatment (McMurran, 2009). It is a dynamic factor that is thought to affect and to be affected by the staff–adolescent therapeutic relationship (Diamond, Hogue, Liddle, & Dakof, 1999 ; Sameroff, 2010), and it is considered to be a precondition and result of effective treatment (Miller & Rollnick, 2002). Olver, Stockdale, and Wormith (2011) conducted a meta-analysis of predictors of offender treatment attrition and its relation to recidivism, and they even concluded that treatment motivation is the most important factor contributing to treatment success. Notably, treatment motivation is considered to be the core of the responsivity principle, one of the three major “what works” principles of effective judicial interventions (risks, needs, responsivity model [RNR]; Andrews & Bonta, 2010). The responsivity principle states that correctional treatment programs should be fine-tailored to the abilities, learning style, and motivation of the offender. Measuring treatment motivation in secure juvenile facilities, in particular youth correctional institutions, poses specific problems. Juvenile delinquents, in particular those with aggressive tendencies, may bluntly refuse to cooperate or show subtle forms of reactance, like sabotaging tests or producing socially acceptable answers (Breuk, Clauser, Stams, Slot, & Doreleijers, 2007; Tourangeau & Yan, 2007). Moreover, many juvenile delinquents have a limited span of attention, often suffer from mild intellectual disability (having an IQ between 60 and 80 and experiencing social problems; Kaal, 2011; Kaal, Brand, & Van Nieuwenhuijzen, 2011), or have difficulties in reading or understanding complex questions. Existing instruments that measure treatment motivation often contain many questions, which are long and ambiguous, and therefore difficult to interpret. These drawbacks pose significant threats to the validity and reliability of the instruments that measure treatment motivation of adolescents in a secure setting. Therefore, Verdonck and Jaspaert (2009), in their review of treatment motivation questionnaires, recommended the development and validation of a valid and reliable instrument for the assessment of treatment motivation in juvenile delinquents, specifically for use in a juvenile forensic institution, which is the focus of the present study.

Treatment Motivation Treatment motivation is defined by Miller and Rollnick (2002) as “a state of readiness or eagerness” to seek out help and work actively at a solution, and it is thought to be


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part of a more general aptitude to adaptively respond to changing environmental conditions (Morisson, Benett, Van der Helm, & Juffermans, 2010). Treatment motivation literature in the forensic area is currently dominated by two theories: self-determination theory (SDT; Deci & Ryan, 1985, 2000) and the transtheoretical motivation model (TTM; Prochaska & DiClemente, 1986). SDT is a theory of self-motivated behavior along a continuum from heteronomy (external motivation) to autonomy (internal motivation). At the heteronomous end of the continuum, behavior is motivated by external regulation, whereas at the autonomous end of the continuum, behavior is fully self-determined. The TTM is an empirically derived stage model of intentional behavior change, which derives its theoretical basis from several theories, such as psychodynamic and cognitive-behavioral theory (Prochaska & DiClemente, 1986; Prochaska, DiClemente, & Norcross, 1992). Although there is a vast body of empirical evidence that supports the validity of the dimensions along which treatment motivation develops, such as (pre)contemplation and action, it does not seem to be warranted to consider these dimensions as distinct stages that are mutually exclusive and follow an invariant sequence (Little & Girvin, 2002, 2004; Morisson et al., 2010; Verdonck & Jaspaert, 2009; West, 2005). In addition, evidence for a sequential model of treatment motivation in offender populations seems to be lacking (Casey, Day, & Howells, 2005; Williams, McGregor, Zeldman, Freedman, & Deci, 2004). Van Binsbergen (2003), using the Dutch version of the Motivation for Treatment Questionnaire (MTQ) with incarcerated adolescents, found only two main motivational factors: readiness to establish therapeutic “contact” and “decision to change,” reflecting the active stadia of treatment motivation. Van der Helm, Klapwijk, Stams, and Van der Laan (2009) conducted a study in a sample of 49 incarcerated adolescents and found only one factor, namely, active treatment motivation. Empirical evidence for the dynamic (i.e., changeable) nature of treatment motivation and its importance for treatment success is found in the vast body of research on motivational interviewing (MI; Lundahl & Burke, 2009; McMurran, 2009). MI was developed from clinical practice and derives its theoretical underpinnings from SDT (Markland, Ryan, Tobin, & Rollnick, 2005; Vansteenkiste & Sheldon, 2006) and TTM (Muscat, 2005; Velasquez, von Sternberg, Dodrill, Kan, & Parsons, 2005). McMurran (2009) conducted a meta-analysis of 19 studies of MI in offender populations and concluded that “MI could lead to improved retention in treatment, enhanced motivation to change, and reduced offending” (p. 83).

Treatment Motivation and Therapeutic Living Group Climate Casey et al. (2005) reviewed evidence for the application of TTM to prison populations and questioned the stage sequences of the TTM model, although not its general principles pertaining to attitudes, thoughts, beliefs, values, self-efficacy, and decision making in the change process. According to Casey, specific characteristics of a prison


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environment, in particular lack of possibilities for self-efficacy and decision making, seem to hamper development of treatment motivation as proposed by the TTM model. However, there is recent evidence showing that a positive living group climate can stimulate an internal locus of control and subsequently (internal) treatment motivation (Van der Helm, 2011). A closed or repressive living group climate, on the other hand, can foster distrust and reactance and could, therefore, hamper treatment motivation and rehabilitation (Schubert, Mulvey, Loughran, & Loyosa, 2012).

Treatment Motivation and Aggression Aggression is considered a major problem in juvenile correctional settings, hampering treatment due to its negative effect on therapeutic alliance between adolescents and group workers, and because aggression contributes to a closed, repressive living group climate (Griffin & Hepburn, 2007; Harvey, 2005; Toch & Kupers, 2007; Trulson, 2007). Incarcerated adolescents do not tend to perceive their aggression as a problem for themselves, but merely as a way of solving social problems (Van der Helm & Van Genabeek et al., 2011). To date, there is no research examining the relation between treatment motivation and aggression.

Development of the Adolescent Treatment Motivation Questionnaire (ATMQ) Verdonck and Jaspaert (2009) reviewed 27 instruments measuring treatment motivation and concluded that although some instruments seemed promising, only one instrument was sufficiently validated for use in (forensic) institutional youth care, namely, the MTQ, based on the TTM of Prochaska and DiClemente (Van Binsbergen, 2003) and the work of Miller and Rollnick (2002) on MI. A serious drawback of the MTQ is its length, grammatical difficulty, and cognitive complexity, which hampers use in adolescents with a short span of attention, adolescents who generally have difficulties in comprehending difficult concepts, and/or adolescents with mild intellectual disability. Therefore, Van der Helm et al. (2009) developed a brief and simplified version of the original MTQ designated as the ATMQ, based on a thorough inspection of the MTQ items. MTQ items that consisted of more than one sentence, items containing difficult or figurative language, and items that together with the response categories produced a double negation were rephrased or removed. The original 5-point scale was transformed to a 3-point scale, consisting of “thumbs-up-or down” pictures, because a study by Van der Plas and Meier (2007) showed adolescents with a mild intellectual disability to have difficulties in interpreting a 5-point scale. The adapted questionnaire consisted of 32 items and was subjected to a principal components analysis, which yielded a one-dimensional solution in a study among 59 adolescent boys and girls in detention (Van der Helm, Klapwijk, Stams, & van der Laan, 2009). Subsequent analyses showed that the questionnaire could be shortened to an 11-item scale, while retaining sufficient reliability.


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The aim of the present study was to test the construct and concurrent validity of the 11-item ATMQ by means of confirmatory factor analysis (CFA) and examining the relation with living group climate to establish the internal consistency reliability of the ATMQ, and to examine the degree to which the ATMQ is sensitive to socially desirable responding (discriminant validity) in a sample of adolescents with severe behavioral problems and delinquents placed in a Dutch secure correctional facility with a therapeutic living group structure. We also explore relations between treatment motivation, age, sex, and self-reported aggression.

Method Participants The sample consisted of N = 263 adolescents, n = 222 boys (84.4%) and n = 41 girls (15.6%). Adolescents were living in a secure residential youth care facility (61%) and a youth prison (38%); approximately 54% of the adolescents were diagnosed with a mild intellectual disability. The mean age of respondents was 14 years (SD = 2.5, range = 12-20 years). The mean stay in the institution at the time of filling out the questionnaire was 14.5 weeks (SD = 15.2, range = 1-74 weeks).

Procedure All adolescents participated voluntarily (response rate of 95%), signed an informed consent declaration, and were told that their answers would be treated confidentially and anonymously, and would be accessed only by the researchers. As a token of gratitude for their participation, participants received a telephone card or a small gift of €5.50. All names on the questionnaires were deleted and given a code number in SPSS. To protect the privacy of the adolescents, researchers had no access to the names. Questionnaires were administered by specially trained graduate students of the Leiden School of Social Studies (bachelor of social work and master youth care) and the University of Amsterdam (Department of Forensic Child and Youth Care Sciences). The research project has been reviewed and approved by the institutional review board of Leiden University of Applied Sciences.

Measures ATMQ. This questionnaire was derived from the MTQ, based on the TTM of Prochaska and DiClemente (Van Binsbergen, 2003) and consists of 11 questions measuring the active phase of treatment motivation as a single construct. The 3-point answering scale used thumbs pictures for better comprehension. An example of an item is “it is good for me to be here” (see Table 1). The treatment motivation score was the mean score of the items, and a higher score indicated greater treatment motivation (see Table 2).


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Table 1. Confirmatory Factor Analysis of the ATMQ (Items and Standardized Estimates; N = 263) Standardized estimates

Item 1. It is good for me to be here 2. My treatment helps me 3. I talk with group workers 4. I want to talk with others about myself 5. I better tell all my problems to the group workers 6. I trust group workers 7. I talk with group workers about my problems more than I used to 8. I learn to work at my future here 9. I think about my behavior 10. I want to change my behavior together with others 11. I talk about my problems with others

.516 .660 .553 .571 .556 .668 .443 .553 .578 .563 .440

Table 2. Means, Standard Deviations, and Correlations Between Treatment Motivation and Living Group Climate

(1) Treatment motivation (2) Open climate (3) Closed climate

M

SD

(2)

(3)

2.05 3.18 3.50

.580 .742 .688

.697**

−.392** −.434**

**p < .01

The Burke–Durkee Hostility Inventory (BDHI). This was originally developed by Burke and Durkee (1957) and was revised by Buss and Perry (1992). Lange, Hoogendoorn, and Wiederspahn (1995), who translated the instrument into Dutch, found two independent factors: overt (direct) and covert (indirect) aggression, rated by boys themselves on a “true”–“not true” dichotomous scale. Direct aggression represents the combination of physical and verbal aggression. Anger and hostility are the core concepts of indirect aggression. Lange et al. (1995) reported good reliability and construct validity. Others have reported good predictive validity and temporal stability (Biaggio, Supplee, & Curtis, 1981; Brunner, 1991). An example of a direct aggression item is as follows: “If I am angry, I slam doors”; an indirect aggression item is “if somebody is nice to me there is always something behind.” In the present study, reliability was found to be good for the direct and indirect aggression scale (Cronbach’s α =.77 and .73, respectively). Social desirability. The tendency to give socially acceptable or desirable answers was assessed with the social desirability subscale of the BDHI (Lange et al., 1995). An example of an item is “I never detest anybody.” Internal consistency reliability of the social desirability scale was .55 (five items).


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Prison group climate instrument (PGCI). The PGCI (Van der Helm, Stams, & van der Laan, 2011) consists of 36 items rated on a 5-point Likert-type scale, ranging from 1 = I do not agree to 5 = I totally agree. Each item belongs to one of the four scales for group climate. The support scale (12 items) assesses perceived professional behavior and, in particular, the responsivity of group workers to specific needs of the inmates. Paying attention to inmates, taking complaints seriously, respect, and trust are important characteristics of support. An example of a support item is “group workers treat me with respect.” The growth scale (8 items) assesses learning perceptions, hope for the future, and giving meaning to the prison stay. An example of a growth item is “I learn the right things here.” The repression scale (9 items) assesses perceptions of strictness and control, unfair and haphazard rules, and lack of flexibility at the living group. An example of a repression item is “you have to ask permission for everything here.” The group atmosphere scale (7 items) assesses the way inmates treat and trust each other, feelings of safety toward each other, being able to get some peace of mind, and having enough daylight and fresh air. An example of a relationship item is “we trust each other here.” The support, growth, and atmosphere scales can be combined to form the scale for open climate (Cronbach’s α’s was .84). Cronbach’s alpha of the repression or closed climate scale was .75.

Results A CFA was performed on 11 items of the ATMQ. CFA is a special form of factor analysis (in contrast to exploratory factor analysis, where all factor loadings are free to vary), which allows for the explicit constraint of certain loadings to be 0. CFA is designed to test whether measures of a construct are consistent with a researcher’s understanding of the nature of that construct (or factor). Table 1 presents the factor solution, showing the items and the corresponding factor loadings that were all significant. Fit indices (Comparative Fit Index [CFI], Tucker–Lewis Index [TLI], and root mean square error of approximation [RMSEA]1) and the model chi-square, also designated as the generalized likelihood ratio, were used to evaluate model fit (Kline, 2005). The following cutoff values are indicative of close model fit: Normed Fit Index [NFI] and CFI > .90, TLI > .95, and RMSEA < .06; whereas, a nonsignificant chisquare indicates exact model fit (Arbuckle, 2007; Hu & Bentler, 1999; Kline, 2005). The model showed a good fit to the data, indicating construct validity of the ATMQ. The RMSEA was .045, CFI = .97; TLI = .961, χ2 (41) = 62.66, p = .00. The RMSEA was lower than .05, the ratio between the χ2 statistic and the degrees of freedom was 0.65 and lower than 2.5, and the CFI and TLI were larger than .90. The scale also proved to be reliable, with an internal consistency of α = .84. Treatment motivation was not significantly associated with social desirability, which supports discriminant validity of the ATMQ, and age and sex of the respondents. Treatment motivation was positively related to an open and responsive climate (r = .697, p < .01; Table 1.) and negatively related to a closed climate (r = −.392, p < .01), which supports concurrent validity of the ATMQ. We exploratively examined associations between treatment motivation and aggression, but we did not find significant relations.


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Discussion This study examined the validity and reliability of the ATMQ in a group of adolescents placed in a Dutch secure correctional facility with a therapeutic living group structure. Evidence for construct validity, reliability, concurrent validity, and discriminant validity of the ATMQ was found in CFA, reliability analysis in terms of internal consistency, and by examining the relations between treatment motivation and living group climate, social desirability, age, and sex, showing that the ATMQ can be used to validly and reliably assess treatment motivation within secure juvenile treatment facilities. No relation was found between treatment motivation and aggression. It is plausible to suggest that such relation is conditional on the degree to which incarcerated adolescents experience their aggression directed at peers or staff to be a problem for themselves. There is empirical evidence showing that for juvenile delinquents, aggression is a “normal” way of dealing with difficult social situations inside and outside secure institutions (Matthys, Cuperus, Maassen, & Van Engeland, 2001; Van der Helm & Van Genabeek et al., 2011). In our interviews (not reported here), many incarcerated adolescents reported to only feel safe at the living group if they knew how to aggressively defend themselves (see also Eichelsheim & Van der Laan, 2011). According to many group workers, aggression reflects lack of treatment motivation (Van der Helm, Van Genabeek, Stams, & Van der Laan, 2011; Van der Helm et al., 2009), but this does not seem to be a valid interpretation given the lack of association between aggression and treatment motivation. Group workers may give up offering support due to misinterpretations of adolescent aggressiveness, which can result in a “deviance amplifying feedback cycle” of aggression and coercion (Lambert, Altheimer, Hogan, & Barton-Belessa, 2011; Patterson & Bank, 1989; Van der Helm, Boekee, Stams, & Van der Laan, 2011). The ATMQ could be important not only for measuring the precondition for effective treatment of juveniles in closed institutions but also for assessing the therapeutic effects of group treatment in terms of treatment motivation development itself (Lane & Rollnick, 2009). It has been shown that decreased treatment motivation is often the result of a closed (repressive) treatment climate (Haralambos & Holborn, 1995; Harvey, 2005; Van der Helm et al., 2009). A predominantly repressive living group climate—with a lack of responsiveness from group workers—a grim and competitive group atmosphere, and violence among the incarcerated delinquents and staff may have great consequences for treatment motivation and subsequent rehabilitation (Kury & Smartt, 2002; Maitland & Sluder, 1998; Schubert et al., 2012). In secure residentialand correctional youth care, control is often the main focus of the institutions and treatment motivation is taken for granted (van der Helm et al., 2009). Maintaining a positive living group climate and stimulating treatment motivation could create possibilities for change. This could possibly be accomplished by applying MI. There are some limitations to this study that need to be acknowledged. As the present study only provides preliminary evidence for the validity and reliability of the ATMQ, results should be replicated in a study with a larger sample size. A future


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validation study of the ATMQ should also examine convergent and predictive validity of the ATMQ. Convergent validity can be assessed by relating group climate to other instruments assessing treatment motivation, whereas predictive validity can be established by predicting recidivism from differences in treatment motivation (see Schubert et al., 2012). Notwithstanding these limitations, the ATMQ has the potential to be an important instrument for research on treatment motivation and effectiveness of (judicial) interventions, targeting rehabilitation of delinquent youth and adolescents with severe behavioral problems in secure institutions. The possibilities for application of the ATMQ are promising, because the ATMQ assesses treatment motivation in terms of factors that are basic in achieving positive treatment effects in secure forensic facilities, such as the need for help, communication, and trust. Interventions in residential youth care could therefore benefit from accurate assessment of treatment motivation to be able to monitor and target treatment motivation as a necessary (but not sufficient) condition for treatment effectiveness. Acknowledgment The authors thank Mark Meijer and Mark van der Plas, group workers at Curium LUMC, for their contribution to this research.

Declaration of Conflict Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was partly financed by a “Raak Publiek” grant.

Note 1. Comparative Fit Index, Tucker–Lewis Index, and root mean square error of approximation are indices of goodness of fit that are independent of sample size. Models that fit well score favorably on these fit indices. For further references, see Arbuckle (2007).

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