Alcohol and other drug continuing care for young people: identifying helpful program mechanisms

ABSTRACT

‘Continuing care’ refers to the provision of co-ordinated care and support overtime. Currently, little is known about continuing care programs for young people who complete alcohol and other drug treatment. This paper analyses data from an interview-based study that aimed to identify the generative mechanisms underpinning an innovative continuing care program for young people. Researchers recruited 11 current and former program clients aged 17 to 25 years and nine program staff. Analysis identified five generative mechanisms of the program that supported participants to manage their substance use over the long term, namely person-centred counselling; relationship stability; safety and inclusion; situated mode of ordering continuing care; and organizational memory. Participants reported that the best continuing care for young people is holistic, includes regular and sustained contact, employs an innovative approach to intervention, establishes links with community services and other support structures, and provides care within a safe, person-centred, and situated framework.

KEYWORDS:

• Youth
• substance use
• continuity of care
• qualitative research

Introduction

Alcohol and other drug treatment and care

Around half of people treated for alcohol and other drug (AOD) use relapse within the first year after entering a treatment program and they remain at an increased risk of relapse overtime (Blodgett et al., 2014). To reduce rates of relapse and to improve the social and health conditions of affected people, continuing care programs, which address the full continuum of care from detoxification to ongoing monitoring and support, have been developed and implemented (McKay, 2009). Continuing care programs for adults comprise a range of formal and informal intervention strategies such as counselling, casework, telephone support, and peer-directed self-help groups that aim to prevent substance use relapse (Ingram et al., 2022; Lenaerts et al., 2014; McKay, 2009). Systematic reviews evaluating the effectiveness of continuing care programs have shown mixed results, often due to a small number of high-quality studies and the varying methodological approaches used to measure outcomes (Blodgett et al., 2014; Lenaerts et al., 2014; McKay, 2009; Savic et al., 2017). Notwithstanding these limitations, some evidence shows that a flexible approach to continuing care service delivery can lead to reductions in AOD use, gambling, and criminal activity, and improvements in adults’ physical and mental health, family and intimate relationships, employment, educational activities, and in securing independent housing (Ingram et al., 2022; Magor-Blatch, 2013).

Young people in AOD treatment and care

Relative to research among adults, fewer studies have focused on AOD treatment and care for young people aged 13 to 25 years who experience multiple disadvantage (Bryant et al., 2022; Caluzzi et al., 2023; Caruana et al., 2023; MacLean et al., 2013). This is despite AOD use in young people accounting for a large proportion of the global burden of disease, and a driver of increases in AOD use (Mokdad et al., 2016). Youth is a time when many health-related behavioural patterns and diseases become ingrained. Three-quarters of lifetime mental health conditions develop prior to age 24, and of the top ten causes of disability-adjusted life-years among young people, five directly relate to mental health or AOD use-related conditions, making them the leading cause of disability among young people globally (Marel & Mills, 2017). For young people who use substances and have complex needs related to poverty, homelessness, comorbidity, and/or disability, there are significant obstacles to accessing, navigating, and completing AOD treatment (Fomiatti et al., 2021; McManus & McManus, 2023), including limited social and material resources and extensive waiting lists for social services (Bryant et al., 2021). Youth retention within AOD programs is important for achieving positive outcomes, yet research into client and program characteristics has been inconclusive with regards to which factors improve treatment retention (Schroder et al., 2009). It is important to understand how young people perceive their substance use (Green et al., 2013; MacLean et al., 2013), their imagined futures (Caluzzi et al., 2023), and their experiences of AOD care (Caruana et al., 2023) to design youth friendly AOD services that improve engagement, retention, and outcomes.

Continuity of care

As a conceptual framework, continuity of care is a model that has long been employed within primary health care (Gulliford et al., 2006). However, it has received much less attention in AOD care. Typically, continuity of care in primary health aims to provide a continuous caring relationship with a health care provider where clients experience a seamless delivery of diverse health services (Gulliford et al., 2006). While it is associated with high quality care, better health outcomes, greater equity and lower healthcare related costs for people and populations (Uijen et al., 2012), there is no clear definition of what continuity of care should involve, and it is often conceptually entangled with related ideas such as coordination of care, integrated care, client-centred care, case management, and aftercare, resulting in diverse practices (MacLean et al., 2022; Uijen et al., 2012).

Generative mechanisms

Generative mechanisms explain why observable events occur (Blom & Morén, 2011) and in the context of AOD continuing care are the underlying elements of programs that help produce self-reported reductions in substance use among clients. There is little research into the generative mechanisms underpinning continuing care programs that sustain long-term goals among young people following AOD treatment, partly because of the reduced attention continuing care has received in the AOD field, and the emphasis on ‘diagnose and treat’ approaches (Bryant et al., 2022). Some evidence indicates that AOD continuing care for youth comprises comparable interventions to those found in adult programs but have also included innovative mechanisms and approaches such as experiential learning, adventure activities, and community-based experiences (Russell & Gillis, 2023). However, generally the mechanisms that guide and strengthen continuing care for young people remain poorly understood in research, health, and social policy, especially in the AOD sector where services are underfunded (MacLean et al., 2022; Magor-Blatch, 2013; Naert et al., 2017).

This lack of precision is evident in a systematic review of continuity of care in youth services (Naert et al., 2017), which used a three-dimensional conceptual framework from general practice comprising relational, management, and informational continuity to analyse youth services research. When these three dimensions of continuity are provided, young service users should experience continuity of care as coherent and connected in their contacts with service providers (Naert et al., 2017). The authors found, however, that youth services research utilizes diverse and vague definitions of continuity of care, studies rarely focused on continuity of care, and when they did, this was usually limited to aspects of care management. The other dimensions of relational and informational continuity were poorly represented in youth services research. Few studies probed the perspectives of young service users and there were few reports from young people who had experienced care continuity. One study (Duroy et al., 2003) reported on young people who had experienced continuity of care within an AOD treatment program, and young people linked continuity with feeling understood, receiving unconditional support, and with motivating engagement and retention in the program.

Background to the continuing adolescent life management program

The Continuing Adolescent Life Management (CALM) program is one of the only known AOD continuing care programs for young people in Australia. It is an initiative of the Ted Noffs Foundation (2023), which is Australia’s largest provider of AOD treatment and continuing care for young people. One of its guiding principles is that young people have different needs for AOD treatment and care than adults. Clients are aged from 13 to 18 years and their interaction with program service providers ranges from daily contact to occasional contact, depending on a client’s needs. CALM program staff assess clients’ risk levels via ongoing engagement and the program allows clients to link back into residential rehabilitation if they are assessed as needing further AOD treatment, or if a client requests further treatment. Clients can access the CALM program up to the age of 18 years, but it is not uncommon for CALM staff to maintain relationships with clients once they are over 18 years old, even if contact is not regular.

This paper identifies and explores the generative mechanisms underpinning the CALM program, which supported young people’s successful management of their substance use after leaving residential rehabilitation. Our findings are based on analysis of the perspectives of program practitioners and service users regarding helpful program mechanisms, and the barriers to successfully implementing these mechanisms. While our findings are from an Australian AOD continuing care program for young people, they are also relevant in a global context, and can inform international AOD continuing care programs for young people.

Method

Participants and procedure

The study received ethical approval from UNSW Sydney Human Research Ethics Committee (No. HC200881). From 2020 to 2023, a purposive sampling frame (Campbell et al., 2020) was used to recruit staff and clients of the CALM program, which operates in Sydney and Canberra. Young current and former clients were nominated by staff and were given an information sheet. If interested, clients were encouraged to email a researcher from UNSW Sydney, and/or to speak to CALM staff for further information about the study. In addition, a list of all CALM program staff members was provided to the researchers and staff were sent an email invitation to participate.

The study used a cross-sectional design comprising qualitative semi-structured in-depth interviews. All participants provided verbal informed consent prior to interview and each client participant received AUD $40 cash for their time. Staff were not remunerated for their interviews. Interviews were conducted either face-to-face or via telephone and lasted from 45 minutes to one hour. An experienced researcher with a background in youth counselling conducted all interviews. Interviews were audio-recorded and professionally transcribed. Pseudonyms were assigned to each of the clients. For staff interviews, participants were designated as either management or frontline, and numbered sequentially. Interviews with young clients used non-technical language and maintained a conversational tone. Young clients were asked about why they joined the CALM program, what aspects of the program they found to be most helpful, what they might like to see changed in the program, and the ways they keep in touch with the CALM staff. Staff interviews included questions about the perceived goals of the program, the mechanisms through which the CALM program is thought to address clients’ needs, how the program mechanisms and outcomes might vary for different young people, and what program elements worked best in addressing clients’ needs and why. Staff were also asked about the historical and political context of the program, its guiding values and staff and management structures to examine how these impacted the program’s capacity to sufficiently resource young people.

Analysis

Analysis of interviews draws on thematic strategies (Braun & Clarke, 2006, 2021) to identify prevalent experiences of what worked in continuing care service provision for young people, and any differences and complexities in these perspectives. Authors JB and MH conducted the analysis, and all co-authors contributed to interpretation of themes. Analysis included both inductive and deductive/theoretical components (Braun & Clarke, 2006). Identification of the main themes was driven by the data, and deduction facilitated a detailed understanding of themes. Following repeated reading of the transcripts and memo writing, the dataset was entered into NVivo 14 for coding, categorization, and thematic analysis. Two overarching sets of generative mechanisms were identified, namely relational and structural program mechanisms. These accounted for: the relationships clients and staff forged with each other; participants’ relationships with the organization and with external services; and the elements embedded within the CALM program that participants said maximized engagement and positive outcomes from continuing care, including reduction of substance use. Further analysis identified the main themes within each of the mechanisms. The themes describe the elements of the program that participants believed were key to client engagement, and which contributed in a meaningful way to improvements in participants’ self-reported substance use.

Results and discussion

In all, 11 young people and nine program staff members were interviewed (N = 20). Young participants were aged from 17 to 25 years and included five women and six men. Eight young participants identified as Caucasian/White, two identified as Aboriginal and one participant reported being of mixed ethnic background. All young participants came from lower socio-economic backgrounds and had not completed high school at the time of their participation in CALM. Ten young participants were former CALM clients, and one participant was a current client. Staff participants comprised three women and six men who were employed in the design, implementation, and administration of the program. Five staff were in management positions and four were in frontline roles.

The main CALM programmatic generative mechanisms identified during analysis were, person-centred counselling; relationship stability; safety and inclusion; situated mode of ordering continuing care; and organizational memory.

Person-centred counselling

Our inductive analysis indicated that person-centred counselling was a key relational and structural mechanism employed within the CALM program, and was conducted using face-to-face, telephone and online methods. Person-centred counselling is a non-directive approach to counselling, based upon unconditional positive regard, empathy, and congruence (Rogers, 1951). It is a style of counselling widely practised among medical and non-medical care professionals (Kirschenbaum & Jourdan, 2005; Marchand et al., 2019). Grounded in a phenomenological-existential ideology, a counsellor’s role is to facilitate the development of young people’s sense of autonomy to become socially integrated functioning beings (van den Akker, 2019). Participants’ accounts revealed that this method of counselling helped young people to improve their interpersonal relationships, to build a sense of autonomy, self-confidence, and self-efficacy, and to facilitate self-learning. By listening to and creating space for individuals to choose their own directions, clients came to understand themselves and their experiences, their problems and how to resolve those problems.

So … learning how to regulate emotions and stuff. And I talk to my CALM counsellor … I feel like finally I’m at a good place after running for this long, which is a relief. (Chanelle, former client, 20)

This nondirective counselling approach included the core conditions of unconditional positive regard, empathic understanding and importantly congruence between clients’ and counsellors’ therapeutic goals. These elements were described by staff as the building blocks to developing trust, rapport, and positive change in the lives of young people, many of whom had experienced significant life challenges. A person-centred approach permeated all aspects of the service, not just counselling, and it was a core value promoted among staff.

… [The Ted Noffs Foundation] does … have a very genuine person-centred culture or philosophy … I think the person who started the whole idea of doing person-centred stuff was Ted himself [the founder]. So … the executive team have been particularly strong at continuing … that philosophy. And I think Noffs attracts people with … the same sort of … values, yeah. (Staff 3, Management)

The amount of counselling was tailored to individual client wishes. On one hand, some young people preferred an informal engagement, whereby counsellors and clients had occasional contact. There was no pressure on a client to continually engage. On the other hand, some young people sought regular contact with their counsellors. Our findings showed how CALM staff developed a strong rapport with each client through person-centred counselling, and they helped young people to identify a broad range of supports, such as their peers and family members, relevant services, and support organizations.

I think, if I didn’t have my counsellor when I got out this time, I probably, like my counsellor got me my house and stuff … I wouldn’t have had a house or … nuh. I probably just would have gotten out and used again, to be honest. (Phoebe, current client, 17)

Person-centred counselling for young people with substance use, offending, and mental health issues requires appropriately skilled and experienced practitioners. Some counsellors working in the CALM program had no formal counselling qualifications, and some staff had post-graduate qualifications in psychology. A staff member explained how supervision helped to address the variable skillsets in counselling and how mentoring assisted less experienced staff to manage challenging interactions with young people.

I always tell my staff as well like, you know, it doesn’t matter what you’re doing … if you’re consistent … with your approach to the young person, you’re always treating them with unconditional, positive regard. It doesn’t matter if they call you a dickhead like, you know … ‘I’m gonna work with my client,’ that means it doesn’t matter what happens … But they know that they can come to you, and you always treat them the same … And, in the back end, there’s a lot of work to do … Like, you know, staff supervision and stuff like that … it’s not easy but that’s where the gold really is … (Staff 9, Management)

A CALM staff member reported that person-centred counselling demanded a considerable allocation of staff time and resources. They believed that staff shortages limited the amount of time counsellors were available to provide in-person support. Similarly, geographical distance was said to present challenges to the provision of person-centred counselling when clients transitioned from the AOD treatment program to the CALM program and returned to their hometown or region. Social media was used by staff to maintain contact with a client, but these platforms were described as unsatisfactory for conducting counselling.

Consistent with Rogerian principles, the CALM program counsellors viewed young people as evolving beings, always changing but always connected to society, culture, and their environment. Their demonstration of unconditional positive regard, empathy, and congruence enabled self-directed learning and a sense of connection to community. There is good evidence for the effectiveness of person-centred counselling (Kirschenbaum & Jourdan, 2005), including a systematic scoping review of patient-centred care for people in AOD treatment (Marchand et al., 2019). Marchand et al. (2019) review described the four core principles, in order of representation in the literature, as therapeutic alliance (defined by characteristics of empathy and non-judgement), shared decision-making, an individualized focus to care, and holistic care that includes an integrated delivery of substance use, health and psychosocial services. These core principles align with the person-centred method of counselling and care revealed in our analysis of the CALM program.

Relationship stability

In our analysis, relationship stability was identified as a key relational mechanism that was an outcome of empathic, non-judgemental, person-centred counselling focused on building trust and rapport with young clients. Relationship stability develops in the presence of stable, safe, nurturing, and mentoring relationships that comprise mutually satisfying levels of communication and trust (Schofield et al., 2013). Studies into the influence of adult mentors, including on high-risk behaviours, have shown a range of positive impacts of stable relationships for adolescents (Beier et al., 2000; Schwartz et al., 2012; Spencer & Liang, 2009). In our study, young clients recognized that their counsellors and caseworkers often had similar backgrounds and life experiences to them, and this similarity seemed to be foundational in forging stable therapeutic relationships. Young people said they valued CALM caseworkers with personal experience of substance use and treatment.

People who’ve actually had a bit of life experience sort of have to be a bit more realistic with what actually is happening … they actually can understand what’s going on. (Arlo, former client, 22)

When a young person entered the CALM program, staff reported that they quickly set about forming a close professional relationship with them. Counsellors and caseworkers enacted a ‘straight-up’ relational style that spoke directly to clients and communicated clearly and respectfully, while defining and maintaining professional boundaries. Staff felt that young people responded well to this relational style because it was plain, understandable, and perceived as non-threatening. Staff sought to find a balance between ongoing engagement with clients without being over-bearing.

Our staff has … got a fantastic ability to be very straight-up with them … He’s [Caseworker] got good boundaries and … he’s not afraid to just pull them up and tell them what he thinks, which the young people actually really appreciate … if you’re very straight-forward with the young people, that’s the way they prefer it. They feel safe because, you know, they grow up with people that they’re really not sure what they’re thinking and what’s gonna happen next. So, to be confident with somebody’s approach to you is important. (Staff 3, Management)

Fundamental to relationship stability was the modelling of positive interactions. Staff said they were aware of how their interactions with young clients, and with other CALM staff members, were an opportunity to demonstrate healthy, stable adult relationships. Often, clients viewed their counsellors and caseworkers as role models, which were missing from their experiences of family and other adults. Young people spoke enthusiastically about the dependable relationships they formed with CALM staff. A young client likened her caseworkers’ role to parental guidance without excessive paternalism.

I’ve still got some really good friends that were workers there who, you know, really cared. And, yeah, they’re like my only adult like connections still … I feel like I got a lot of really good imaging from there. Like … a lot of the time when I try and figure out how I need to act in a situation … I feel like when I came to [drug treatment] I was … under-educated on myself and how to talk to other people, and how to behave … ‘cause I don’t have a lot of a good image of like how to act and how to be an adult … [CALM staff] they’re … really healthy people and, yeah … feels like mums and dads … (Azalea, former client, 19)

CALM staff modelled consistency and dependability in their interactions with young clients. Similarly, staff said they carefully intervened if they assessed a client’s relationship with their family was in trouble. In some circumstances, young clients reported that staff had helped them to recover broken family relationships, to stabilize relationships, or staff had acted as a bridge for communication between clients and families. CALM caseworkers were said to require specific qualities to build stable relationships including grit, patience, persistence, and determination. Typically, a good caseworker needed to be curious and genuinely interested in every aspect of their clients’ lives. They had to be flexible in their approach to engaging with clients yet tireless in their efforts to build relationships and to ensure ongoing contact.

You know … the sheer doggedness sometimes of our … workers just going like, ‘Okay. I can’t reach their mobile … I’ve got mum’s number. Let me try mum. You know, let me try this person. Let me try that person.’ Like, you know, really trying to get hold of that young person. You know, ‘Let me add them on Facebook and I’ll send them a message there.’ You know, ‘Let me try and figure out what’s going on.’ And in building that relationship as well, like that helps because later on, when we’re trying to figure out what’s going on for the young person, you build up that network, but you have to just be really proactive about doing it. I think that’s the thing. (Staff 9, Management)

Value alignment facilitated young people’s perceptions of caseworkers as authentic individuals and role models who shared similar experiences and views of AOD use, families, peer networks, and marginalization. Furthermore, value alignment contributed to trust and by extension, relationship stability. Overall, clients regarded their best caseworkers as dependable, caring, experienced, perceptive, good listeners, and discreet. They said they admired workers’ positive attitudes, hardiness, and conciliatory skills, and they had respect for workers who were undeterred when clients presented with challenging behaviours. Moreover, staff investment in relationship building with people from services outside of the CALM program provided a conduit for referral for young people to re-enter drug treatment if needed, or to access external care and support services they could trust once someone had left the program.

Past research has found that in the absence of stable, safe, and nurturing relationships, adolescents appear to face increased risks of poor social outcomes including lower academic achievement (Schofield et al., 2013). Our findings align with earlier research around AOD service-engaged young people and the value of forming strong, dependable, and validating relationships with service providers who young people perceived as authentic and respectful (Green et al., 2013), especially when this can be incorporated as a program mechanism within AOD continuing care.

Safety and inclusion

Our analysis identified safety and inclusion as key relational and structural generative mechanisms of the CALM program. Being safe and included helps young people feel secure, understood, and respected, enabling them to develop intimacy, trust, self-efficacy, and a sense of belonging with others (Habib, 2012). In AOD services, heteronormativity and racism are known barriers to safety and inclusion (Farnbach et al., 2021; Mullens et al., 2017). In our study, staff challenged instances of casual homophobia among young people, and clients reportedly felt safer when they perceived their sexual and cultural identities were acknowledged and genuinely valued. Self-directed learning and its corollary of self-healing was facilitated by CALM staff who strived to provide a safe space devoid of judgement, threats, or exclusion.

I think the strengths of CALM would be that … they’ve got a good team there that, you know, looks after all the young people. It’s a safe space, culturally, and for the queer community … and it’s … like a very safe space for me. Like I felt really comfortable … to go there and, even though I’m not in that program anymore, like I’ll still go in and say hello … [later] [CALM] set me up for a lot of things and kept me connected with culture and education, and all things that I didn’t have … beforehand. (Jarrah, former client, 25)

Many young people in the study had experienced stigmatization and intergenerational trauma so safety and inclusion were described by participants as integral to maintaining client engagement. Caseworkers strived to connect young people to their cultures and communities, for example by referring clients from First Nations backgrounds to culturally specific programs. Staff pooled resources and experiences around safe and inclusive practices with workers from regional and interstate CALM programs to support clients who had returned to rural and regional homes. Staff viewed long-term connections with young clients as an indication of success in their efforts to create safe spaces and used client feedback to work towards continually improving these spaces.

I think we try to make the space feel inclusive and we have regular meetings around how we can make it feel more inclusive. And I guess … that’s tied in with feedback that we get from LGBTQI+ young people that we get. So, we’re concentrating on feedback from them. And I guess it’s also just linking them in with other services that we know, especially with our like Indigenous clients as well … referring them on. (Staff 6, Frontline)

Nonetheless, clients identified challenges to establishing safe and culturally inclusive spaces. Few staff employed in the program were from diverse cultural backgrounds, including from queer communities, which limited opportunities for powerful role modelling.

I think they need more Aboriginal staff, which I think a lot of places need; not just [CALM]. No, [it doesn’t have] too many weaknesses, to be honest. I think, yeah, just … more Aboriginal staff … (Jarrah, former client, 25)

The work of building safe and culturally inclusive spaces that are experienced as transformative for young people is in confronting and deconstructing systems of power such as racism (Ferdman, 2017; Habib, 2012) and heteronormativity (Steck & Perry, 2018). In our study, there was awareness among staff and young clients that safety and inclusion needed to be strong programmatic mechanisms for young people to feel well-supported in managing their substance use long-term.

Situated mode of ordering continuing care

A situated mode of ordering continuing care was identified in our analysis as a key structural programmatic mechanism of CALM. A situated mode of ordering continuing care is defined as the foregrounding of socio-material interventions that address the political, material, relational and structural circumstances each young client experiences, such as requirements for education, housing, employment, and social connection (Hart, 2018). It related closely to the other structural and relational program mechanisms of safety and inclusion, person-centred counselling, and relationship stability, and helped CALM staff to understand their clients and to situate interventions that addressed their individual needs. Young people’s life-histories and experiences, their life-challenges and achievements, their interests, the people they valued in their family and peer networks, and their goals in life informed staff development of personalized interventions that would motivate young clients to create positive change with respect to their substance use.

[I]n CALM I think it should be about, yes, getting them into education and a driver’s licence, and bank account. Like they’re the essentials. But, also, helping them find their spark. (Staff 2, Frontline)

The CALM program offered a variety of practical, protective, individualized interventions that were enacted in a client’s preferred order and pace, such as vocational education and training programs that aligned with clients’ lifegoals. Young people were encouraged to set their own goals, and the role of staff was to help clients achieve these. Caseworkers said they aimed to be flexible and to work with clients as their goals changed. The program blended creative activities, including music, art, and sports, with situated interventions to build and sustain engagement in the program.

… [L]ike the CALM team was always like really helpful. Like really like tried to get me engaged on the things I wanted to do in life. Like that’s … the only reason I have like the life I have now is because they helped me sort out the kind of like world I wanted to put myself in, and my caseworker got me enrolled in TAFE [Technical And Further Education], in music. (Azalea, former client, 19)

Interventions based on the specific situation and needs of clients included driver training, basic life-skills education, and securing stable accommodation. Young participants said they valued interventions that focussed on future planning to strengthen avenues for their lives post-care. They believed there was a good balance between staff giving helpful advice about future life strategies and acknowledging client autonomy. Some young clients said that interventions such as crisis management had exceeded their expectations of what continuing care could achieve. One staff member (Staff 9) described CALM as a ‘lighthouse’ and a ‘beacon’ for young people to explore and experience opportunities for personal development, and an ‘outreach umbrella’ that referred and linked young people’s specific needs to other helpful services. Staff attempted to address service fragmentation via networking with services beyond the CALM program. Caseworkers found the right personalized support for young clients by ‘casting the widest net’ (Staff 8), sometimes drawing in external organizations such as sexual health services to provide multidisciplinary expertise, but always leaving the door open for clients to return.

… I think there would be a number of young people who would be, you know, pretty significantly disadvantaged if not from … the lack of regular contact, certainly, the lack of that lifeline back in times of crisis. ‘Cause we know with our young people too some of them like, when they fall, they fall hard and they fall quickly. It’s not sort of this slow decline over, you know, a year or two. It’s like over the course of two weeks life’s gone from this to complete chaos; unmanageable, you know. Relapsed on the drug use. (Staff 8, Management)

A situated mode of ordering continuing care intervention was a key structural mechanism that built tangible skills and inculcated a sense of hope and optimism in young clients (Caluzzi et al., 2023). It identified lifegoals which really mattered to young people and provided an individualized and humane allocation of care and resources.

Organizational memory

Our analysis identified organizational memory as a vital structural generative mechanism, which ensured ongoing engagement with young people to support management of their substance use. Organizational memory is defined as the accumulated expertise and experience of management, counsellors, and caseworkers, including their beliefs, ideologies, norms and values, habits, rituals, and work environment that influence present workplace decision making (Walsh & Ungson, 1991); informally expressed as ‘the way we do things here’. Organizational memory resides within a variety of spheres including workplace culture, among individuals, in information technology systems, and in structures such as departments. CALM staff described the importance of mentoring, long-term networking with social, health and community organizations, and shared engagement strategies, case management expertise, knowledge, and experience of implementing interventions.

Like … the whole development of how we work with kids on social media, that is something that I wouldn’t have been able to work out a parameter around how to do. But there are other people who had I guess skills and some … capacity to do that. So, and then, you know, me being able to share groups or resources around how to actually apply for things or do something, those things were great. (Staff 4, Management)

While our findings indicated that organizational memory provided a blueprint for building intra- and inter-agency connections, it also reinforced a shared sense of purpose and identity among CALM workers as experts in adolescent continuing care management. Organizational memory also provided current and former clients with a sense of program continuity and safety, which enabled young people to remain connected with the program and its staff, sometimes over many years.

Yeah. So … it’s been very cool to progress and have someone who I think is at the program for so long … Like it’s nice that the turnaround with the service isn’t to the point where you wouldn’t know someone after a certain amount of time. (Campbell, former client, 23)

Organizational memory is threatened, however, when experienced and well-networked staff move on to other employment. The program’s functioning depended upon retaining advanced skills in person-centred counselling, relationship building, safety and inclusion and in implementing situated interventions. Staff reported that the CALM program had been largely successful in retaining its experienced staff and in maintaining connections with other services, despite the stressful nature of the work. It was stated that management’s awareness of workers’ stressful roles helped staff retention. Participants said that the organization trained, supervised, and mentored CALM caseworkers extensively and genuinely cared about staff wellbeing. Experienced caseworkers and counsellors worked to mentor less experienced staff, and the organization made efforts to support staff mental health.

I find my manager’s really good at it [preventing burnout and compassion fatigue]. Yeah … in the sense of like … if he’s aware of a challenging client or … an event that might have been, you know, hard to deal with … I would say [Noffs] they’re pretty good at dealing with, you know, staff feeling like they need [help]. (Staff 6, Frontline)

Reportedly, complicated funding arrangements, reduced funding, and frequent policy changes had impacted CALM organizational memory. In response to reduced funding, caseloads had increased, and staff shortages threatened the capacity of the program to deliver its preferred suite of activities. Where possible, staff innovated to find a balance between funding constraints, changes to programs and the strategies required to satisfy young people’s needs.

Funding is always something that’s … at the back of your mind … And, you know, that’s one thing where we’re constantly worrying about … and, also, being able to have like longevity because right now in the role … it does sort of boil down to funding and the number of personnel that we can put in … (Staff 9, Management)

AOD treatment services in Australia are funded using an episode-of-care model. An episode-of-care is defined as any completed course of AOD treatment undertaken by a client that achieves significant treatment goals such as reduced substance use (Moore & Fraser, 2013). Research suggests that an episode-of-care funding approach, among other effects, encourages fragmented service provision and undermines delivery of long-term support (Moore & Fraser, 2013). In practice, it means service providers need to be skilled at bridging gaps in service funding for their clients to fully experience continuing care. This funding environment does not support organizational memory and long-term engagement. Indeed, CALM workers skilled in bridging funding gaps created by an episode-of-care approach had left the program. In a project-based organization such as The Ted Noffs Foundation, expert knowledge is accumulated among staff and shared between the organization and any loss of knowledge over time can impact the organization. From participants’ perspectives, organizational memory was imperative to maintaining high quality continuing care for young people.

Conclusion

In general, we found a robust concordance between accounts provided by young people and CALM staff members regarding the generative program mechanisms identified in this study. Participants were overwhelmingly supportive of the program, confident of its capacity to assist marginalized young people and positive about the values that underpinned it. Person-centred counselling, relationship stability, safety and inclusion, a situated mode of ordering continuing care, and organizational memory were highly valued by young people and by staff alike and were seen as aspects of the program that kept young clients engaged and on positive trajectories. In our analysis, young people viewed sustained change to their self-worth as a resource they could use to positively shape their future beyond the program. While safety and inclusion were viewed as critical program mechanisms, these were also among the hardest to achieve and maintain. Staffing limitations impeded the program’s ability to respond to all clients’ cultural needs, something that is identified in other research (Farnbach et al., 2021; Mullens et al., 2017). Despite this, referral pathways helped to ensure at least some aspects of cultural need were met by the program. Reported constraints on the funding needed to hire and adequately train staff, and by extension to reduce staff workload, burnout, and turnover, highlight a need for increased and consistent funding of continuing care.

Study limitations

The findings presented in this paper are from a study that had several limitations. We did not recruit a representative population of young people in AOD continuing care programs and therefore the findings are not generalizable. The results may be affected by selection bias. Also, most young people interviewed were former program clients, so their interviews provided retrospective accounts of their experiences of the program. More current clients in the sample might have provided a different balance of perspectives, including information about other generative mechanisms and limitations of the program not presented here. Additionally, the findings are drawn from two urban contexts and as such they are limited to a specific program in two settings. Finally, the sample comprised young cisgender women and men, therefore our findings offer no insight into the experience of transgender young people and those who identify as non-binary in AOD continuing care. However, consistent with the research aims, the study’s approach to recruitment helped identify a variety of generative mechanisms in an AOD program. While the findings are not generalizable, they may be transferable and relevant to similar international AOD programs.

The analysis in this paper reveals the architecture through which continuing care programs for young people can be delivered using program principles that are relevant to and valued by young people (Bryant et al., 2022). It demonstrates how relational, informational and management continuity leads to young service users experiencing continuity of care as coherent and connected in their contacts with service providers (Naert et al., 2017). Quality continuing care can act as a foundational resource for maintaining a positive trajectory after AOD treatment by: offering clinical care in a format that gives young clients unconditional positive regard; offering stable and dependable relationships with mentoring adults that can connect them to other resources; offering other practical interventions that are delivered in modes situated within and oriented to the specific needs of each young person; offering services that seek to be safe and culturally inclusive; and delivering this consistently over the long term. Continuing care programs that establish a safe and inclusive space, build opportunity for stable ongoing relationships, and provide interventions that align with clients’ lifegoals are thought to best support young people to manage their substance use, and to re-establish links between young people and their family, community services and other support structures.

Acknowledgments

This research was supported by an Australian Research Council Discovery Grant DP200100492 ‘Aftercare for young people: A sociological study of resource opportunities’, with additional funding from the UNSW Interlude grant scheme 2021. The project is a partnership between UNSW Sydney Australia, La Trobe University Melbourne Australia, Kings College London United Kingdom, YSAS Youth Support Advocacy Services, and The Ted Noffs Foundation. The research was supported by the excellent contributions of Dr Rebecca Gray, Ora Davidson, Mitchell Beadman, Dr Jacqui Sundbery, Mark Ferry, and Andrew Bruun. The research team is grateful for the support provided by the staff of YSAS, Windana, Ted Noffs Foundation and Lives Lived Well residential rehabilitation, residential detoxification, and housing programs. We are particularly grateful to the young people who shared their stories about substance use and treatment experiences for this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to confidentiality and anonymity requirements contained in the study’s ethics approval, interview data is unavailable.

Additional information

Funding

The work was supported by the Australian Research Council [DP200100492].