This study examined how Aboriginal and Torres Strait Islander young people, following 30 or more days in a ‘mainstream’ residential drug and alcohol treatment program were faring after treatment. The analysis compared data at admission to community follow-up at least 3 months post-discharge. To our knowledge, this is the first study to undertake treatment follow-up measures with this population.

This study demonstrates therapeutic communities are an intervention worthy of further examination in relation to preventing self-harm and suicide among Aboriginal and/or Torres Strait Islander people, whose rates are among the highest in the world (Dudgeon et al., 2016). This study found a significant decrease in self-harm post compared to prior to the program among those who were able to be followed up. Reported suicide attempts also significantly decreased. However, it is important to acknowledge that attempted suicide or self-harm may have been the catalyst for entering the program, which may create a reversion to the mean as suicide attempts and self-harm may reduce regardless of the program.

Significantly fewer Aboriginal and Torres Strait Islander young people reported using alcohol again since completing the program, with fewer days using alcohol for those who continued to drink. Number of drugs used, and frequency also significantly reduced, and the Severity of Dependence Scale scores significantly improved. These results suggest the program and its components have contributed to reducing drug and alcohol use for at least some of the Aboriginal and Torres Strait Islander young people who participated in the program. Despite a significant reduction in the number using cannabis post treatment compared to baseline, 64% of the sample were still using cannabis at follow up. The reasons for the lack of impact on the use of cannabis among these young people requires further research. The improvements in life circumstances and reductions in related problems surrounding alcohol and drug use, such as arrests were found. It is well-known that Aboriginal and Torres Strait Islander young people are over-represented in youth detention, with a majority in adult prisons having previous periods of incarceration (ABS, 2017; Fox et al., 2013; Whitesell et al., 2013). The specific role of this program in possibly contributing to a reduction in arrests requires further investigation. Research shows imprisonment is costly not only to governments, but also to prospects of genuine rehabilitation as it erodes individual and community health (Francis, Cheryl Lero, & Daniel, 2011).

There were no significant differences for Aboriginal and Torres Strait Islander young people spending time with friends who did not use drugs or spending a fair or a lot of time with family pre-to post program. A change to peer networks can be important post treatment given the potential influence peer groups can have on young people’s drug and alcohol use (Brown et al., 2008; Engels, 2003). The reason why this change in peer networks did not occur for many of the young people in this study is not able to be determined from the current study data, but it may be the case that it takes more time than 3 months for young people to make connections with other young people who don’t use drugs. This may also be more challenging for Aboriginal young people as friends who use drugs may include those with whom they have kinship connections (Bennett et al., 2013).

The finding that time spent with family, often seen as an important source of support (Tsey et al., 2010), did not change is important and not necessarily a negative finding. For some young people, their family of origin may be a source of stress, and time away from them whilst in a TC and in the first few months post treatment discharge may help reduce pressure on relationships and contribute to improving family dynamics in the longer term (King et al., 2009; Waldram, Herring & Young., 2006). For those who did spend time with family, no significant improvements were recorded using the Family Assessment Device (FAD) 3 months after program discharge compared to before admission. With mean scores remaining above the clinically significant threshold, family is clearly a potential stressor for many of the young people who were in the program, as evident in other studies with Indigenous peoples’ (King, Smith & Gracey., 2009; Waldram, Herring & Young., 2006). Further attention to understanding the impact of family relationships in treatment and after care are needed. This is particularly important for Aboriginal and Torres Strait Islanders among whom ‘family’ often includes extended networks, not only immediate blood relatives. Aboriginal and Torres Strait Islander people have particularly enduring and instrumental kinship connections vital for identity, belonging and cultural knowledge transfer (Bennett et al., 2013), which helps to counter frequent experiences of racism (Tsey et al., 2010) reduce alcohol and drug use and develop resilience and strength (Brady, 1995). The conceptualisation of family in the tool used in the current study may not capture the broader notion of family for many Aboriginal and/or Torres Strait Islander people.

The loss to follow-up in this study is a limitation. Loss to follow-up is an issue in many adolescent drug and alcohol treatment studies (Tripodi, 2009; Williams & Chang, 2000) and this is likely to be more challenging when these young people also identify as Indigenous. It is possible that the subgroup of program participants who were doing well post treatment compared to those who were not were more likely to respond to a follow-up survey request. However, even though the follow up group may not have been representative of all those who stayed 30 days or more, the findings that there was a significant reduction in key harms, including self-harm, suicide attempts, substance use and arrests is nonetheless an important contribution to the field. There is a complete lack of published data on Aboriginal and Torres Strait Islander young people following residential drug and alcohol treatment and the current study suggests there could be positive outcomes for these young people from such programs. However, based on the current study design, causality cannot be attributed to the program, and any improvements could also be due to time or some other factor not measured in the study.

A comparison was made between those who were followed up and those lost to follow up and no differences were found on key socio-demographic measures or among key variables which were the focus of the analysis except that a higher proportion of young women were followed up compared with young men. This is a limitation of the study. Young men are possibly harder to follow up in the community as at baseline young men were significantly more like to be court involved than young women and this difference may persist post treatment for those young men lost to follow up. Additionally, those lost to follow up had a significantly shorter length of stay than those who were followed up.

The current study was focussed on those who had a length of stay of 30 days or more given the relationship between length of stay and outcomes (Darke et al., 2012; Edelen et al., 2010; Galaif et al., 2001; Mills et al., 2013; Orlando et al., 2003). A further analysis of the factors associated with retention in programs for Aboriginal and Torres Strait Islander young people would be useful to inform program design to better meet client needs and improve length of stay.

A further limitation is that the measures used were not developed specifically for Aboriginal and Torres Strait Islander young people. The service has used the best available and accepted measures in the field and the psycho-social measures have been validated in a range of studies as detailed in Table 1. Further, the changes found pre/post in the current study were in response to direct questions asking about behaviours, such as drug use, arrests, and self-harm rather than psychological scales with multiple items. Where scales were measuring more complex constructs, such as family functioning, we found no change, and this may or may not reflect a problem with the scale itself and its applicability to Aboriginal and Torres Strait Islander young people as discussed above. The strengths of this study include the co-design and collaboration with Aboriginal community organisations.

Implications and future directions

Findings of this study provide some support for the capacity of ‘mainstream’ drug and alcohol residential treatment programs to provide positive outcomes for Aboriginal and Torres Strait Islander young people. Culturally-relevant modes of treatment and support are particularly important when Aboriginal and Torres Strait Islander young people are over-represented in the client group compared to in the community population (Gray et al., 2014; Taylor et al., 2010) as is the case with this program. In addition, there is a need to formally review programs to understand how they incorporate culturally relevant modes of caregiving to improve outcomes among young Aboriginal and Torres Strait Islander people. There is also a need to develop a robust tool for the measurement of outcomes post drug and alcohol treatment specifically for young people, including domains of life improvement that may be particularly relevant for those who identify as Aboriginal and Torres Strait Islander.