Steven L. Jaffe, MD, Ashraf Attalla, MD, and Diana I. Simeonova, Dipl-Psych, PhD
CHAPTER OUTLINE
■ TREATMENT MODALITIES
■ FAMILY THERAPY
■ COGNITIVE–BEHAVIORAL THERAPY
■ TWELVE-STEP APPROACHES
■ THERAPEUTIC COMMUNITIES
■ MOTIVATIONAL TREATMENT
■ USING MULTIPLE THERAPIES
■ RELAPSE AND CONTINUED CARE
Treatment of adolescent substance use disorders involves a number of issues that are quite different from those seen in adults with substance abuse problems. First, the adolescent’s biopsychosocial level of development must be considered. For example, it is normal for young adolescents (age 12 to 14 years) to be self-centered, experience mood shifts, and have minimal capacity for introspection. This profile makes therapy with early adolescents very different from the treatment of older adolescents. Second, since adolescents still are developing within a family system, family members must be part of the treatment program. Third, adolescents differ from adults in their patterns of substance use, as adolescents are more apt to use multiple drugs and to use inhalants in early adolescence and club drugs in late adolescence and early adulthood. Fourth, some studies have shown that current comorbidity is more common among adolescents than adults (1) and integrated treatment of the comorbid condition is especially important in adolescents.
After careful evaluation, giving full consideration to the foregoing issues, the physician should make an individualized determination as to the appropriate treatment placement for the substance-involved adolescent. The American Society of Addiction of Medicine has developed placement criteria for adolescent treatment (2) that include the dimensions of treatment readiness, relapse potential, and recovery environment (see Chapter 105, “Placement Criteria and Strategies for Adolescent Treatment Matching”).
Given the heterogeneous nature of substance use and the relative lack of adolescent treatment research to date, it is not possible to recommend one specific treatment modality that is likely to be effective for all adolescent patients. Instead, researchers and clinicians generally recommend the inclusion of specific treatment elements (e.g., cognitive–behavioral therapy, family and group treatments, motivation enhancement, 12-step meetings) and a continuum of care in all treatment modalities. Currently, several treatment modalities are available and have been utilized in the treatment of adolescent substance abuse and dependence. Most of the available adolescent substance user treatment programs are based on adult treatment models; however, they typically include modifications to address the special needs of adolescents. This chapter describes the treatment approaches most commonly employed in the treatment of adolescents.
TREATMENT MODALITIES
In 1990, Catalano extensively reviewed the literature on adolescent treatment and found that, in residential programs, time in treatment was related to reduced use of alcohol or other drugs. Family participation was associated with better outcome. No treatment modality was significantly better than any other. Catalano could only conclude that some treatment was better than no treatment.
Significant progress has been made in adolescent treatment and relapse prevention in the past two decades. The National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the Center for Substance Abuse Treatment have increased their support and direction for controlled studies of adolescent treatment, as well as for the development of clinical researchers to study such treatment. The American Academy of Child and Adolescent Psychiatry has published both a 10-year research review (3) and “Practice Parameters for the Assessment and Treatment of Substance Abuse in Children and Adolescents”
(4). Improved standardized assessment instruments and adolescent-specific outcome measures have been developed.
A number of treatment approaches have been used alone or in various combinations for the treatment of adolescent substance use, abuse, and dependency disorders. A Treatment Improvement Protocol on adolescent treatment, published by the Center for Substance Abuse Treatment (1999), describes the three most commonly employed treatment approaches as family therapy, 12-step–based programs, and therapeutic communities (TCs). More recently, a systematic review of the literature on evidence-based psychosocial treatments for adolescent substance abuse found that the factors of longer duration of treatment, increased readiness to change substance abuse behavior, and family involvement were associated with better outcome during treatment (5). This review concluded that three treatment approaches— multidimensional family therapy (MDFT), functional family therapy (FFT), and group cognitive–behavioral therapy (CBT)—emerge as well-established models for treatment of this population. The researchers also pointed out that none of the treatment approaches appeared clearly superior and that other therapeutic modalities were efficacious as well. These and other important modalities are reviewed below.
FAMILY THERAPY
Family therapy is the most studied modality in adolescent substance abuse treatment (6). Classic family therapy is based on the hypothesis that there is a connection between family relationships and the development or maintenance of drug abuse. Family therapy targets these specific interpersonal family processes. With structural–strategic family therapy, emphasis is on establishing a coherent family hierarchy, with appropriate rules and authority. A very early family therapy approach was the Purdue Model. Lewis et al. (7) combined a number of different family therapy models to develop a 12-session treatment called the Purdue Model, the goals of which were to decrease family resistance to treatment, to redefine substance use as a family problem, to reestablish parental influence, to interrupt dysfunctional sequences of family behavior, to assess the interpersonal function of the drug abuse, to implement strategies to change family interpersonal functioning, and to provide assertiveness training to the adolescent. Families that received this treatment model were found to have significantly decreased adolescent drug abuse compared to families that received parent skills training.
A recent meta-analysis (8) of the family treatment of delinquent adolescents with substance abuse examined the efficacy of four family therapies, that is, brief strategic family therapy (BSFT), FFT, MDFT, and multisystemic therapy (MST). All four had statistically significant but modest effects compared to treatment as usual or alternate therapies.
Multidimensional Family Therapy
Liddle’s MDFT has established the most empirical support for efficacy. MDFT is an outpatient family-based treatment that combines substance abuse treatment with multiple system assessments and interventions within the family and the surrounding psychosocial environment. MDFT usually involves therapy sessions one to three times per week over 3 to 6 months both in the home and at the clinic. Treatment domains of the adolescent, parents, family, and extrafamilial are addressed. A therapy assistant may help with the areas of school, economic assistance, or addressing substance abuse treatment for other family members. A very positive, empowering, nonpunitive atmosphere with a strong therapeutic alliance is created. In a randomized clinical trial with 182 marijuana- and alcohol-abusing adolescents, MDFT showed superior improvement among patients compared to a multifamily educational intervention and adolescent group therapy. The treatment improvement was maintained during 6- and 12-month follow-up assessments. At 12-month follow-up, 45% of MDFT patients reported clinically significant reduction in drug use, compared to 32% and 26% in the adolescent group therapy and the multifamily educational intervention conditions, respectively. Further, at 12-month follow-up, the MDFT patients demonstrated significantly improved social functioning, as demonstrated by improved academic achievement and family functioning (9). Further studies have established MDFT as an effective evidence-based treatment (5).
Brief Strategic Family Therapy
This is a manualized family therapy structural–strategic approach developed for Hispanic families with behavior problem youth. A recent randomized trial of 126 youths compared BSFT to group therapy (10). BSFT treatment resulted in significant reduction of self-reported marijuana use and parent-reported conduct problems. BSFT was also more efficacious than group therapy in improving family functioning.
Multisystemic Therapy
Henggeler’s MST integrates family therapy with direct interventions in the multiple interacting systems involving the individual, school, peer group, and community. This treatment approach promotes responsible behavior among all family members and attempts to develop each individual’s capacity to manage his or her own problems. Therapists work intensively with each adolescent and family in the home, school, and even neighborhood peer group. MST has demonstrated excellent retention rates and favorable outcomes (11). A randomized clinical trial of 118 juvenile offenders with a diagnosis of substance abuse or dependence examined MST compared to community service provided through the local office of the state substance abuse commission (12). MST significantly reduced substance use at posttreatment, but the effect was not found at 6- or 12-month follow-up assessments. The total days of out-of-home placement for patients in the MST condition were reduced by 50% at 6-month follow-up compared to patients in the community treatment condition. Henggeler et al. (13) conducted a 4-year follow-up assessment of 80 patients participating in this clinical trial. In this study, the findings regarding substance use were mixed, with biologic measures indicating 55% of MST participants to be abstinent compared to 28% of participants in the community treatment condition. However, self-report outcome measures of substance use did not differentiate between treatment conditions. There was a significant decrease of aggressive behavior by MST. A recent review of therapies for substance-abusing adolescents with conduct disorder demonstrated that those providing family therapy had the best outcomes with MST showing the most compelling evidence (14). Another study (15) suggested that integrating MST into juvenile drug court improved substance abuse outcomes. MST is also integrating contingency management (CM) to try to improve results.
Functional Family Therapy
FFT integrates behavioral and cognitive interventions with ecologic–family relationship strategies. A recent study showed FFT and FFT with CBT to be efficacious at 4 months compared to individual CBT or group psychoeducational therapy (PET) (16).
Behavioral Family Therapy
Azrin (17) combined family therapy with behavior therapy such that parents reinforced drug-incompatible activities, supervised home urge control assignments, and employed written specifications of desired behaviors with contingent reinforcers. Abstinence rates at 6 months were 73%, while the control group of supportive counseling was only 9%. A more recent study showed equal efficacy to cognitive problem-solving therapy (18).
COGNITIVE–BEHAVIORAL THERAPY
This therapeutic modality combines the learning principles of classical and operant conditioning with approaches to correct cognitive distortions and underlying negative belief systems. Treatment involves teaching the adolescent specific techniques to deal with drugs and alcohol. Specific skills to refuse alcohol and drugs are taught and practiced in role-playing exercises. For example, the adolescent is taught to immediately say “no” in a firm manner, making direct eye contract with the person who offers alcohol or drugs. They are then to suggest an alternative activity or, if that is not successful, to simply tell the person to stop asking.
Cognitive–behavioral coping skills to deal with urges, to manage thoughts of alcohol or drug use, and to handle emergencies and lapses are taught and practiced. Because deficits in coping skills for negative feelings and life stresses contribute to continued substance use, more general coping strategies (such as communication skills, problem-solving strategies, anger and mood management, and relaxation training) also are taught and practiced.
A number of randomized clinical trials provide empirical support for the efficacy of CBT in the treatment of adolescents with substance use disorders. Kaminer et al. compared CBT group therapy with interactional group therapy (IT) in adolescents with co-occurring substance use and psychiatric disorders. CBT demonstrated a decrease in severity of substance use but did not produce better results than IT at 15-month follow-up (19). A randomized clinical trial of 88 predominantly dually diagnosed adolescents compared the treatment efficacy of CBT versus PET in this population (20). Patients were assigned to one of the two 8-week outpatient group psychotherapy conditions and were assessed at 3- and 9-month follow-up. Older youth and male participants in the CBT condition showed a significantly lower rate of positive urinalysis than did PET participants at 3-month follow-up. Also, self-report decline of substance use was reported from baseline to 3- and to 9-month followup regardless of the treatment condition.
Findings from the Cannabis Youth Treatment (CYT) study provide support for both group and individual CBT interventions for adolescents with substance use disorders (21). Six hundred predominantly white, male cannabis users (average age 16 years) participated in two multisite interrelated randomized clinical trials. The five interventions were 5 sessions of motivational enhancement therapy (MET) plus CBT (MET/CBT5), 12 sessions of MET and CBT (MET/CBT12), Family Support Network, Adolescent Community Reinforcement Approach (ACRA), and MDFT. The main outcome measures were days of abstinence and percent of adolescents in recovery as demonstrated by no use or abuse/dependence problems and living in the community. All CYT interventions across both trials and all four sites produced significant reductions of cannabis use and negative consequences of use from pretreatment to 3-month follow-up. The treatment gains were sustained through the 12-month follow-up. Despite the considerable support for family therapy interventions in this population, the MDFT treatment in the second trial did not produce superior outcomes compared to the individual (ACRA) and individual/ group (MET/CBT5) interventions. The most cost-effective interventions were MET/CBT5 and MET/CBT12 in the first trial and ACRA and MET/CBT5 in the second trial. Although positive results were obtained, these were limited with 40% not responding at all and only 35% to 40% in recovery at 1 year (21).
TWELVE-STEP APPROACHES
Twelve-step approaches are now considered an effective adjunct to substance abuse treatment among adults. The status of the effectiveness of this approach among adolescents has been the subject of relatively recent investigation. Although the 12-step–based treatment is one of the most common treatment models for adolescents, there has been little research into its efficacy. This approach is suitable for teens who have developed severe drug problems and not just recreational or mild use.
The 12 steps guide changes in actions, thoughts, feelings, and beliefs that an individual slowly undergoes in order to establish a state of recovery and abstinence from alcohol. Since an addict cannot use alcohol and drugs in moderation, abstinence is the necessary goal. Working the 12 steps is an extremely concrete process that does not require abstract thinking.
The following descriptions present the first five steps, modified to make them meaningful for adolescents (22).
Step 1
“We admitted we were powerless over alcohol—that our lives had become unmanageable.” For adolescents, the workbook has the adolescent examine in detail the negative consequences of their alcohol/drug use. Putting their own and others’ lives in danger, effects on family, school, work, mood, and self-esteem in relationship to alcohol/drug use are explored. The major issue is whether drugs and alcohol are destroying their lives such that they need to stop using to make their lives better. While many adult programs emphasize the concept of “surrendering” and admitting one is an addict, these are not useful for adolescents. Rather, enhancing power by doing what one needs to do (such as stop using alcohol and drugs) instead of doing what one wants to do (use alcohol and drugs) is emphasized.
Step 2
“We come to believe that a power greater than ourselves could restore us to sanity.” The adolescent workbook approaches this step by recognizing that a child’s first higher power is the person who raises him or her. For many drug abusing/addicted adolescents, their parental figures were neglectful or abusive. Mourning the pain and sadness from the disappointments of their childhood higher powers enables them to begin to develop a sense of something positive in the universe that they can turn to for help. Also in the development of an addictive state, the alcohol/drugs have become a negative higher power that has taken over their life. Stopping the alcohol/drugs leaves a void that needs to be filled by a positive higher power. The higher power concept is not a religious belief but a spiritual feeling that one can trust something positive (e.g., the group, another person, God, or nature) to take care of those aspects of one’s life that one cannot control. One needs to have trust in the stability of the world and realize one controls one’s own behavior but not what others say or do. For many adolescents, the concrete positive feelings of their relationships to other members become the first higher power.
Step 3
“We make a decision to turn our will and our lives over to the care of God as we understand Him.” The adolescent workbook interprets this step to involve having the adolescents make a decision to commit themselves to working the steps and having a positive spiritual power. The teenagers are helped to recognize that they turned over their lives to alcohol and drugs. Now they are being asked to turn their lives over to a positive program.
Step 4
“We made a searching and fearless moral inventory of ourselves.” The workbook has the adolescents answer numerous detailed questions covering all aspects of their childhood and present life.
Step 5
“We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.” In this step, the adolescent verbalizes an inventory to a counselor or a sponsor.
Twelve-step programs also provide the opportunity to attend free Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings, which are conducted several times a day in almost every city and town in the United States and most other countries. It is well recognized that adolescents will return to using alcohol and drugs if they return to contact with their alcohol- or drug-using friends. Twelve-step programs provide the opportunity of a recovering peer group. Twelve-step programs also provide mentoring relationships in the form of sponsors. An older member with at least a year of sobriety, the sponsor, provides support and guidance on how to work the program to achieve sobriety. Twelve-step programs accept the concept of addiction as a chronic progressive disorder that renders the addict unable to control and moderate his or her drinking or drug use. The only viable alternative is complete abstinence (23). For many adolescents, it may be helpful to view themselves as “on the way to becoming an addict,” if they do not see themselves as already being one.
Although research on 12-step adolescent programs has been sparse, there are at least 19 studies using different design methodology to investigate the usefulness of this treatment modality. The formal 12-step–oriented program evaluation studies reported levels of abstinence averaged 30% to 40% across studies and time points. Prevalence of abstinence was at 3 months, 29% and 35% (2 studies); 6 to 9 months, 30%, 51%, and 24% (three studies); 1 year, eight studies ranging from 30% to 66%, averaging 39%; and 2 or more years, 40%, 30%, 30%, 20%, and 50% (five studies) (24).
Important specific studies include the following research. A CATOR residential treatment follow-up study (25) found that teenagers who attended two or more meetings per week were almost six times more likely to report abstinence at 1 year than were those who never attended. A study by Winters et al. (26) used improved methodology with a high follow-up contact rate and meaningful comparison groups. At 12-month follow-up, those adolescents who completed 12-step–based treatment had an abstinence/minor relapse rate of 53%, compared with 27% of those who needed, but did not receive treatment. The favorable outcome continued at 5-year follow-up for the treatment group, especially those attending aftercare NA or AA meetings (27). A recent study of 99 adolescents and 12-step attendance following inpatient treatment (28) demonstrated that AA/NA attendance was uniquely associated with improved outcome. One-third were completely abstinent during the first and second 3-month intervals, and there was a dramatic reduction in substance involvement with the sample as a whole being abstinent on 82% of the days. The major mechanism identified was that 12-step attendance maintained and enhanced motivation for abstinence. Limitations of these studies include lack of random assignment and that only inpatient/residential treatment programs were studied (29). Benefits of AA or NA participation were shown in a followup of 8 years for a sample of inpatient youth (30).
The results of reviews of programs that explicitly mention AA/NA as part of treatment obtain results comparable to other reviews of other treatment modalities suggesting that 12-step formal treatments for teens may do as well as other treatments on average. It also appears that teens that reported feeling connected to others, engaged in a higher frequency of meditation and prayer, and endorsed a more spiritual orientation to life were those who expressed a greater preference for spirituality and the 12-step approaches.
THERAPEUTIC COMMUNITIES
The TC offers long-term treatment (12 to 18 months) to adolescents who have multiple severe problems. In the TC approach, the community itself is part of the treatment process. Residents move through stages of increasing responsibility and privileges. Work, education, group activities, seminars, meals, job functions, and formal and informal interactions with peers and staff form the basis of self- development. The presence of staff who are themselves in recovery and family involvement are important aspects of TCs.
An outcome study found that 31% of adolescents completed the residential phase of treatment in a TC, while 52% dropped out. Treatment completers at 1-year posttreatment had more positive outcomes than those who did not complete treatment, as measured by a reduction in substance use and decreased criminal activity. A recent study examined associations of a multidimensional measure of TC treatment processes (the Dimensions of Change Instrument [DCI]) with treatment retention and posttreatment outcome in 397 and 207 adolescents in residential treatment, respectively. Although, contrary to the expectation, the researchers did not find an association between DCI and treatment retention, they found that adolescents who stayed in treatment 90 days or more tended to be more involved in self-help activities at the posttreatment follow-up. These adolescents had increased likelihood of attending 12-step meetings and having a 12-step sponsor after leaving treatment (31).
MOTIVATIONAL TREATMENT
Prochaska and DiClemente (32) have described a series of stages that mark the progress of an individual toward cessation of alcohol or drug use. These stages are designated as precontemplation, in which the person is not even thinking about stopping and does not recognize any problem with alcohol or drug use; contemplation, which is marked by ambivalence in which the person goes back and forth between reasons to change and reasons not to change; preparation, in which the person increases the commitment to change; action, in which the person stops using alcohol and drugs; and maintenance, in which the person develops a lifestyle to avoid relapse. Individuals exhibit different levels of motivation depending on their stage of change. Therapeutic intervention involves helping the patient in an empathetic, nonconfrontational manner to move along the stages. Miller and Rollnick (33) developed motivational interviewing (also known as MET), which used the strategies of expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacy. Brief motivational interventions consist of one to four sessions, following an assessment, in which direct feedback and advice are given in a nonconfrontational manner that respects the person’s personal responsibility for making a decision.
Monti et al. (34) have studied the use of a single 45- minute emergency department brief motivational interview for adolescents whose injuries are related to alcohol use. The researchers viewed this as a teachable moment. Follow-up studies found that the adolescents who were exposed to the interventions compared to standard care subsequently had fewer alcohol-related problems. Additional support for the efficacy of motivational treatment is provided by the results of a 4-year follow-up study within a randomized trial of 363 college freshmen who reported drinking heavily in high school (35). This trial indicated that participants receiving an individual preventative intervention had significantly greater reductions in negative consequences compared to high-risk controls. The participants receiving the intervention were also more likely to improve and less likely to worsen regarding negative drinking consequences over a 4-year period. Although brief motivational therapy may not be sufficient for those with severe alcohol/drug problems, it is very helpful as an initial approach and can be front-loaded to other treatment.
Intervention Workbook
Both motivational interviewing and 12-step facilitation therapy develop motivation in the adolescent to stop using alcohol or other drugs through the adolescent’s personal recognition of the negative consequences of such use. Jaffe’s Adolescent Substance Abuse Intervention Workbook (36) engages the adolescent in use of this framework to answer concrete, simple questions that explore 12 areas of the adolescent’s life that may have been negatively affected by alcohol or other drugs. The workbook also compares unhealthy thinking (such as “drugs are fun”) with recovery thinking (e.g., “but my life is a mess”). Internal motivation is developed by helping the adolescent to conclude that he or she needs to stop using alcohol or other drugs in order to make life better. A recent study of 56 substance-abusing juvenile delinquents in detention who completed the 2-hour workbook intervention demonstrated an increase in recognition of drug harmfulness especially to marijuana and belief of harmfulness if continues to use as before (37).
Community Reinforcement Approach
Community reinforcement approach (CRA) is a treatment approach originally developed for adults, in which the individual’s life is rearranged so that abstinence is more rewarding than drinking. This modality has been adapted for adolescents, manualized and evaluated as part of the Cannabis Youth Treatment Study (21). The therapeutic approach is warm, enthusiastic, and nonjudgmental as therapists identify adolescents’ and parents’ reinforcers. They then work toward learning and practicing new skills to obtain these positive rewards. Adolescents and their parents are seen separately and together in flexible sessions. A functional analysis of substance use and prosocial behavior identifies triggers. Short-term positive consequences and long-term negative consequences are also noted. Other sessions my involve problem solving, communication skills, and how to achieve healthy social and recreational activities making their environment increasingly supportive of recovery.
The CRA approach closely resembles the “enthusiastic sobriety” adolescent program developed by Meehan (38). This 12-step–based program uses young, energetic, enthusiastic, recovering, well-trained counselors. They are role models who demonstrate that one can have fun without drugs or alcohol. The adolescent is asked to try 30 days without alcohol or other drugs. During this time, the adolescent participates in daily groups, meetings, and social functions with recovering peers who make sobriety more fun and rewarding than using drugs and alcohol.
Dialectical Behavioral Therapy
Dialectical behavior therapy is an empirically validated therapy developed by Linehan (39) that is effective in decreasing self-harming and self-defeating behaviors especially in borderline personalities. This psychotherapy is now being applied to patients with substance abuse including adolescents (40). Dialectical behavior therapy (DBT) combines the CBT techniques for emotional regulation with the skills of mindfulness, distress tolerance, and interpersonal effectiveness. These skills are taught in individual or group sessions and include self-reflective diary cards, homework assignments, and phone contact. A recent controlled pilot study of young adult marijuana users showed a significant decrease of days of use when a two-session motivational interviewing and mindfulness intervention were compared to a control group (41).
Contingency Management
Contingency Training (CM) is based on the premise that drug seeking and drug use are directly modifiable by manipulating the relevant environmental contingencies. CM uses concrete positive rewards to enhance attendance, participation, and abstinence. Numerous studies have demonstrated CM’s efficacy in adult populations. It is just beginning to be studied with adolescent substance abusers. Stanger and Budney (42) have studied CM combined with a parent training program and individual MET/CBT yielding positive results. CM is also being used with vouchers for negative urines in adolescent drug court settings.
Pharmacotherapy
The use of medications in adolescent substance abuse treatment is just beginning to be studied. Nicotine replacement therapy for nicotine dependency, disulfiram aversion therapy for alcohol dependency, naltrexone as a blocker of opiates or to decrease cravings for alcohol, and methadone/buprenorphine as substitution therapy for opiate dependency are some of the strategies being tried (43). Pharmacotherapy of the comorbid disorders, that is, attention deficit hyperactivity disorder, posttraumatic stress disorder, anxiety, and affective disorders, has been more extensively studied (44). With adolescents, pharmacologic interventions should always be used with psychosocial treatments (45).
USING MULTIPLE THERAPIES
No single treatment modality has been demonstrated to be clearly superior. All therapies have a significant percentage of failures. Multiple approaches are being integrated in an attempt to improve outcome. For example, family therapies are combined with MET, CBT, CM, DBT, and 12-step treatments in an effort to increase success.
RELAPSE AND CONTINUED CARE
The most pressing problems in adolescent substance abuse treatment are the large number of treatment noncompleters (which range from 30% to 50% in clinical settings) and the extremely high relapse rate regardless of the treatment used. In the Cannabis Youth Study at 1 year, 30% to 40% were in recovery, and 40% did not respond at all. Follow-up of 12-step program treatment following inpatient care resulted in a 30% abstinent rate with abstainers attending twice as many meetings. Continued care for noncompleters should involve either a different treatment modality or a stepped-up more intensive intervention of the failed treatment. Relapse is common and should be expected. With this frame of reference, it is extremely important not to allow a lapse (return to alcohol or drug use for a few days) to develop into a full relapse (return to use for weeks or months). Some studies showing statistical significant decrease of drug use may not equate to clinical significance.
When counseling an adolescent during a lapse, the physician should minimize guilt and shame. The emphasis should be on what the adolescent can learn from the lapse, for example, avoiding high-risk situations such as the company of “using” peers or seeking out a sponsor for help in dealing with intense thoughts and urges to use.
Jaffe (46) interviewed 30 adolescents who had relapsed and described four pathways that place recovering teens at risk of relapse. The most common is involvement with peers who use alcohol or drugs. Even if the adolescent is committed to sobriety, spending time with using peers becomes too tempting, and the teen relapses. A second pathway is the presence of comorbid psychiatric disorders. Adolescents with substance abuse disorders have a high incidence (50% to 90%) of other psychiatric disorders, especially mood, behavior, and anxiety disorders. In this pathway, the teen experiences depression, rage, or panic and relapses in an effort to deal with those symptoms. A third pathway is denial, in which the recovering adolescent decides that he or she is not an addict and can use alcohol or other drugs in moderation. The fourth pathway involves subconsciously arranging one’s life to be in proximity to alcohol or other drugs. A recent relapse study (47) involved 14 focus groups with a total of 118 adolescents and young adults who were enrolled in substance abuse treatment programs. Analysis for relapse perception themes yielded 90% for emotional reasons that involved coping with negative feelings; 85% for life stresses that included parental criticism and failing school; 65% for socialization processes that included peer pressure; 75% for cognitive factors that included poor motivation and cravings; and 55% for environmental issues that included availability and triggers.
Recovering adolescents working a 12-step program who relapse need to examine the strength of their program and recognize the need for a solid sponsor, a nonusing peer group, and frequent (two or more each week) attendance at AA/NA meetings. All relapsing adolescents should be evaluated for comorbid disorders (such as depression or posttraumatic stress disorder), which may require specific treatment.
A recent development is Assertive Continuing Care (ACC) where continued contact is the responsibility of the therapist. Monitoring by telephone and/or home visits involves education, support, and reintervention. A study of postresidential adolescents yielded a 52% abstinent rate for marijuana at 3 months for the ACC group compared to 32% for the usual continuing care (48).
Kaminer et al. (49) studied aftercare over a month period for youth with alcohol use disorders in an outpatient program. They compared 50-minute individual MET/ CBT, 15-minute MET/CBT therapeutic phone contacts, and a no intervention control group. Positive results resulted for both active interventions and were maintained over 12 months (50). Importantly, the phone intervention was feasible and acceptable. Present-day adolescents are heavily involved with technology, and this form of communication needs to be further explored by adolescent substance abuse treatment researchers.
Jim is a 16-year-old male who was admitted to an intensive outpatient program because he had been arrested for selling cocaine. Drug history included smoking marijuana daily for the past year, alcohol on weekends, occasional snorting of his Adderall, and cocaine weekly for the past month. The counselors of the IOP program establish a milieu of enthusiastic sobriety where the emphasis is on having fun without drugs and alcohol. During the first 2 weeks of the intensive outpatient program, Jim was passively compliant attending groups, lectures, and activities. The staff use a motivational interviewing approach, but Jim was resistant to acknowledging any negative effects of his alcohol and drug use except for the legal issues. In family therapy, the parents worked through some of their angers and resentments at each other that had resulted from their divorce, and they learned to become more unified in setting appropriate limits with Jim. Using contingency management techniques, they began to reward positive behavior and removed his computer and cell phone when he attempted to contact his using friends.
By the 3rd week, his thinking was much clearer, and the staff emphasized to him that the marijuana was out of his brain. He now could make meaningful connections between actions and consequences. He represented his first step from Jaffe’s intervention workbook and this time was able to realize how drugs and alcohol had messed up several areas of his life, that is, putting others in danger because of drunk driving. His depression had gotten worse, his grades decreased, and he broke the law. This 3rd week of treatment became a turning point in his program. At a young people AA meeting, the staff connected him to a young man with 2 years of good recovery who became his sponsor. They formed a very positive relationship such that they would talk on the phone three times a week and together attend AA or NA meetings. He became more active in the CBT skills training groups and learned alcohol and drug refusal skills and techniques to manage drug urges. Because of his chronic depression and his history of ADHD, he was begun on the antidepressant bupropion. Weekly urine drug screens became negative. In the 3rd, 4th, and 5th week of treatment, he wrote his first three steps. He learned that he had turned over his life to the negative power of drugs and alcohol, and now he was following a positive life direction. He learned mindful techniques in his meditation classes and would pray when he felt overwhelmed by negative thoughts and feelings. After discharge, he continued individual, group, and family therapy as well as medication management and AA\NA meetings with his sponsor and other recovering peers.
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