BARRIERS IN MULTIFOCAL PSYCHOLOGICAL COUNSELING IN ADOLESCENTS WITH CONDUCT DISORDER

Multifocal psychological counseling in adolescents with conduct disorder aims to be a form of social support by involving the individual significant for the adolescent and by respecting the participants’ needs.
Family and teachers’ involvement, beside the adolescent with conduct disorder, in a psychological counseling program can increment the decrease of dysfunctional behaviors in adolescent. More so, the family and the teachers themselves can benefit at a personal development level by their involvement.
In this paper, we underline the barriers encountered in the process: the high rejection rate of teachers, parents and adolescents. Rejections were expressed as soon as the proposal to take part in our research was formulated or during the participation, by postponement of sessions, failure in attending the sessions, superficial involvement in the assessment stage that lead to their results invalidation or by lack of involvement in the fore set psychological counseling program.
The results of our research affirm and supplement some assumptions regarding the openness towards psychological services in the Romanian socio-cultural environment, even when these services are free of charge.

Introduction

We support the idea that such a research is necessary in Romania due to difficulties encountered while dealing with these cases (low involvement within the therapeutic process and the need for long time monitoring), but also, due to the fact that there is an insufficient knowledge and use of science based psychological assessment tools and psychological interventions for the adolescent with conduct disorder.
The adolescent with conduct disorder (CD), considered to be refractory to therapeutic interventions, presents itself as difficult cases that, usually show low availability to change once dysfunctional behaviors become personality patterns (Beck et al., 2011/2004; Dlugos & Friedlander, 2001).
In general, the motivation of individuals that show undesirable behaviors and poor relationships to look for professional assistance is externally determined by those who ask for the change (family, school, judicial system) while they believe that their problems derive from others’ inability to accept them thus restricting their freedom (Beck et al., 2011/2004).
We proceed in our study on the premise that change is possible and, as Rogers (2008/1961) stated, that therapy aims to free and facilitate the individual’s inborn drive towards psychological development or maturity, when the fore mentioned drive has been locked. We argue that a multifocal approach during the process of improving the dysfunctional behavior of the adolescent with conduct disorder, predicts the success of the psychological counseling on long term.

School environment influences

According to previous studies (Graham, 1988; Gottfredson, 2001; Herrenkohl et al., 2001) it has been confirmed that individuals with antisocial behavior usually attend schools in which there is low trust between teachers and pupils, low commitment towards school on behalf of the pupils, as well as inexplicit and inconsistent rules. Also, it has been shown that in schools that have consistent, fair and explicit rules, there tends to be a lower number of pupils with inadequate and antisocial behaviors.
The school represents the social and cultural environment in which the teenager is molded but also represents the environment in which the negative impact of conduct disorder is mainly felt. Studies by Achenbach et al. (2008) show that involvement of school representatives within psychological intervention programs specifically designed for teenagers’ issues represents a real support for these adolescents.

Family as therapeutic tool for the adolescent with conduct disorder

As it is well known, the family has a major impact on child development. The outcome can be positive which enables the child to become an independent, responsible and socially adapted adult. But the outcome can also be negative, meaning a disharmonious development. Even in situations where the child/adolescent develops certain undesirable behaviors or disorders, the family plays an important role in his recovery due to the fact that it represents one of the factors that triggers, maintains or facilitates the fore mentioned behaviors or disorders.
We reckon that the family’s role in treating the teenagers’ behavioral issues can be expressed through: (1) an accurate perception of the problems; (2) request for professional aid; (3) providing affective and social support; (4) getting involved as co-therapist in the interventions which address the adolescents.
We believe that involving the parents beside the adolescents in the therapeutic programs, allows them to accurately understand the way their child feels, thinks and acts, opening to them a new perspective that leads to a reassessment of their values and a rearrangement in their lives, as well.

Psychological counseling as therapeutic tool for the adolescent with conduct disorder

Many psychological interventions seem adequate for the conduct disorder, from a theoretical point of view, but the most efficient models that one can find in the professional papers focus on behavioral modeling, enhancement in the sense of social affiliation, cognitive reframing, development of problem solving abilities, change of irrational beliefs, self analysis and development of parenting skills.
The professional literature supports the praxis and efficiency of several therapeutic approaches for the adolescents with antisocial behavior (cognitive-behavioral therapy, module deactivation therapy, family functional therapy, multi-systemic therapy) in several cultures where multiple interventions look to involve the family, the school, the practitioners from several areas, the tax payers and the community as a hole (Carr, 2006; Henggeler et al., 1993; Alexander et al., 1994;).
Interventions on behavioral disorders aim to reduce the symptoms, to modify the different risk factors and to enhance the protective factors, thus being oriented towards treatment or prevention.
We believe that psychological counseling is a useful tool in treating the adolescent with conduct disorder and we reckon that improving the methods and techniques of these types of interventions may lead to an enhancement of the individual’s protective factors as well as to a decrease in antisocial behaviors.

Method and instruments

The main goal of this paper is to underline the barriers encountered during a psychological counseling program designed for the adolescent with conduct disorder which also involved the adolescent’s family and the school, within the Romanian socio-cultural environment.

Group selection procedure
For our research we addressed several high-schools from the western region of Romania, private practices of psychology and child psychiatry from Arad, the Probation Service within the Arad Legal County Court. All these institutions were widely informed regarding the available psychological services.
To perform the clinical psychological diagnosis we used ASEBA. This instrument requires a circular approach: the adolescent self-report (YSR), adolescent’s assessment by the parent (CBCL) and adolescent’s assessment by the teacher (TRF). Therefore, the class teachers and other teachers that interact consistently with the adolescents involved in our research were invited to take part. We asked the teachers to facilitate our contact with the adolescents’ families, to fill in the ASEBA-TRF in order to enhance the accuracy of the diagnosis as well as to take part in the counseling program. The families were accurately and in detail informed on the goals and the course of the research and they were asked for their consent prior to their or their child’s involvement.

Selection criteria
For adolescents : (a) age between 15 and 17; (b) conduct issues present at least at a subclinical level; (c) no mental retardation; (d) signed written consent; (e) parent’s written consent.
For parents: (a) signed written consent; (b) no mental retardation or other mental disorders.
For teachers: (a) signed written consent.

Exclusion criteria: invalid, incorrect or incomplete fulfillment of psychological assessment tools.

Group characteristics

317 adolescents, aged between 15 and 17 (m=16.73; SD=.49), were included in our research; 212 boys (66.88%) and 105 girls (33.12%). All adolescents were school attending as follows: 9th grade – 16 individuals (5.04%); 10th grade – 79 individuals (24.92%) and 11th grade – 222 individuals (70.04%).
The adolescents filled the ASEBA-YSR form in order to assess their conduct problems. Three groups were formed based on the level at which the conduct problems occurred: nonclinical group (116 individuals; 36.60%), subclinical group (109 individuals; 34.38%) and clinical group (92 individuals; 29.02%).
The adult participants included parents and teachers. 172 parents, aged between 39 and 59 (m=46.31; SD=4.63), 33 males (19.20%) and 139 females (80.80%), met the selection criteria. We note that for each adolescent only one parent answered, although both were addressed. The number of teachers willing to take part in our research was low, failing to meet the required statistical criteria for our experimental approach.

Assessment tools

Multiple sources and informants were used to assess and diagnose the conduct disorder in adolescents. We chose informants able to provide accurate and valid data. Also, we selected a range of assessment tools that met criteria such as validity, reliability and usefulness in accordance with standards recommended by field professionals (Fischer & J.,Concoran K., 2007; Hunsley J. & Mash E., 2010). ASEBA plus other seven psychometric tools were used.

Working procedure

The psychological counseling program had to be redesigned due to teachers’ lack of involvement, thus being reduced to a bifocal approach: adolescent – family. The counseling was customized according to each adolescent and family psychological profile and it included several stages based on specific cognitive-behavioral guiding techniques (Dryden, 1993, apud. Marcu 2013; Kazdin, 2000; Ellis, 2001 & 2002). There were 14 counseling sessions, a one hour session a week, for each pair adolescent-family. Participants that attended the counseling sessions were assessed three times: prior to the start of the counseling program, half-way through the counseling program (after 7 sessions) and at the end of the counseling program.

Results

While selecting the participants and forming the groups for the research there was a high refusal rate among adolescents, parents and teachers. Refusals were expressed as soon as we addressed individuals for the research or during the research – either by failing to attend the sessions, postponing them, lack of involvement during the assessment stage that lead to invalid results or lack of involvement during the agreed counseling program.
Most frequent reasons for the refusals were: low time availability, lack of information on available psychological services, low trust in psychological counseling benefits, concern for other family or individual issues. There were cases where refusals had no expressed reasons.

School related difficulties

For our research, we addressed 6 high-schools for a partnership, but only 4 agreed by signing the research partnership form. Out of the 20 classes targeted within the 4 high-schools that agreed the partnership, only 11 classes were included as proposed by the teachers on the account of the classes’ higher level of behavioral issues.

Family related difficulties

Out of the 431 families we addressed, 236 (54.76%) refused to take part in our research. Another 24 families (5.57%) withdrew during the assessment stage, while 23 families (5.34%) were excluded after the assessment stage, due to invalid results (Figure 1.1).
Out of the 92 parents of the adolescents diagnosed with clinical conduct disorder, 36 parents (8.35% of the 431 individuals we addressed) refused to take part beside their child within the intervention program, while 17 parents (3.94%) took part only in the first half of the intervention program (first 7 sessions). Only 39 parents (9.05% of the total 431; 42.40% of the 92 parents of adolescents with conduct disorder) attended the entire intervention together with their child (Figure 1.1 & 1.2). Each family was represented by one parent only.

Families were reluctant to get involved in our research due to specific features they showed and due to the way they perceived this type of services (Figure 1.3). Similar results were found in other studies (Palada, 2012). 29 out of the 92 parents of the adolescents from the clinical group see themselves as victims of their children’s behavioral issues or victims of other existential issues, thus lacking the strength to commit to a counseling process as co-therapists. Others (37 parents), admit the need for social support, but expect that their child’s behavioral issues improve due to the involvement of professionals and teachers, without their own involvement. On the other hand, we noted that some parents (19) have little knowledge on what psychological counseling means, thus showing low trust in this type of professional services.
The type of support showed by families was important for the design of the counseling process. We identified the following types: informational support, assessment support and instrumental support; the later meaning actual involvement.

Adolescent related difficulties

Out of the 431 adolescents addressed, 71 (16.94%) refused to take part in our research. 41 adolescents (9.51%) were eliminated after the initial assessment due to invalid, incomplete or inconsistent protocols and results (Figure 1.4).
Out of the 92 adolescents with clinical conduct disorder, involved in the first stage of the research, 7 (7.61%) were eliminated before intervention and 5 (5.43%) refused to take part in the intervention. 24 (26.09%) out of the fore mentioned 92 adolescents, refused to take part in the counseling program but agreed to be included in the clinical control group, while 56 (60.87%) took part in the 14 week counseling program. Only for 39 (42.39%) out of the 56 adolescents representing the clinical intervention group, the parents agreed to take part in the entire counseling program while for the remaining 17 adolescents, the parents took part only in the first half of the program (Figure 1.4 & 1.5).

Teacher related difficulties

The teachers acknowledge the high number of adolescents with conduct issues as well as the necessity for intervention programs to reduce dysfunctional behaviors, but show little long time availability to get involved beside the adolescents in the intervention program, as showed by our research. Statistically, teachers’ involvement was not significant even within the assessment process.

Conclusions

Data analysis shows that within the regional socio-cultural environment, there is a low openness towards psychological services that address the adolescent with conduct disorder, even when these services are free of charge. Same findings were identified in several other studies and socio-cultural environments (Palada, 2012).
The findings of our research can be summarized as follows:
Only 4 out of 6 high-schools we addressed, agreed to take part in our research.
Parents took part in the entire counseling program (14 weeks) only in case of 39 (42.39%) out of the 92 adolescents with conduct disorder. For other 17 (18.48%) adolescents with conduct disorder, parents took part only in the first part of the counseling (Figure 1.1 & 1.2). For each adolescent only one parent was involved (mother or father), although we addressed the entire family.
Several parents see themselves as victims of the situation. Often, adolescents’ behavioral troubles overlap other problematic existential issues that the family faces which leads to either neglect, denial or overwhelm.
7 (7.61%) out of the 92 adolescents diagnosed with clinical conduct disorder refused to take part in the interventions from the beginning, while 5 (5.43%) were eliminated. Only 56 (60.86%) adolescents with clinical conduct disorder took part in the entire 14 weeks counseling program (Figure 1.4 & 1.5).
Adolescents’ reluctance towards a long term therapeutic process determined us to favor counseling methods and techniques adapted to a short term intervention. The methods and techniques addressed adolescents’ present life, targeting specific issues at cognitive, behavioral and social level.
Teachers’ involvement was not significant at all stages of our research, but one. They didn’t get involved within the assessment process and counseling program, but facilitated our contact with the families in the process of obtaining their informed consent. Thus, the trifocal approach was limited to a bifocal one: adolescent – family. We believe that a greater implication on the part of teachers would have supplemented the results of our study.

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