A blended strategy for adolescent males

According to a 2011 study conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, substance use by teens is the most significant public heath problem in the United States. The CASA study found that 46% of all high school students are currently using addictive substances (i.e., nicotine, alcohol and other drugs), and 1 in 3 of those students meet criteria for addiction.

Probably not surprising to front-line practitioners in the substance abuse treatment field, the CASA report revealed that 90% of adult Americans with addiction began using substances prior to age 18. Addiction as a progressive brain disease has its origins in adolescence, related in large part to the vulnerability of the developing brain during that period.

In addition to the significant increase of risk for addiction, substance use during adolescence has numerous negative consequences and costs, including fatal and nonfatal injuries due to motor vehicle accidents; unintended overdose; sexually risky practices and unwanted pregnancies; and increased risk for medical and mental illnesses. Early identification of, and effective intervention for adolescents with, substance use problems can prevent the disease’s progression from abuse to addiction and, for teens already addicted, the possibility of recovery before incurring the increasingly severe damage and losses tragically associated with adult addiction.

But for intervention to be effective, it is crucial, especially for adolescents, to distinguish between drug abuse and drug addiction. This distinction provides an opportunity for more individualized and effective treatment.

A diagnosis of substance abuse essentially involves impairment in role functioning and repeated harmful consequences without the physiological cravings, tolerance, or withdrawal associated with addiction. Addiction, on the other hand, changes the brain’s structure, chemistry and function in fundamental ways, resulting in a convolution of a person’s hierarchy of needs. With the reward and pleasure centers of the brain hijacked, the result is compulsive behavior that overrides the ability to control impulses despite persistent and severe negative consequences. Addiction, then, is essentially a disorder of thought and behavior.

Not all adolescents who receive substance abuse treatment are substance-addicted. Unfortunately, many adolescent rehabilitation programs are predicated on adult treatment models that fail to appreciate both the general developmental differences between adolescents and adults and the relative severity of the substance use problem along the abuse-addiction continuum. These oversights can result in a failure to engage and retain teens in treatment, unnecessary resistance or superficial compliance, and poor outcomes.

The concept of integrating harm reduction and abstinence-based treatment has been gaining attention during the past decade. Particularly for an adolescent population with co-occurring mental health and substance use disorders, this integration is more powerful than either treatment individually.¹ The strengths of each framework can be combined to provide individualized and comprehensive treatment to adolescent substance users across the continuum of use. Integrating the models provides the opportunity for decreased resistance to treatment, more genuine engagement, and a stronger platform for addressing co-occurring mental health disorders.

It is important to note, and is often misunderstood, that abstinence from all addictive substances is always the goal when working with adolescents. There is no such thing as “safe use” for teens. But in contrast to many strictly abstinence-based programs, an assertion of commitment to abstinence is not a prerequisite for treatment. However, an ultimate goal of abstinence is necessary for physical and psychological health in adolescence, and reinforces a nurturing approach.

Treatment matching

At Rushford at Stonegate, a developmentally focused residential treatment facility in Connecticut for adolescent males with co-occurring disorders, a comprehensive multidisciplinary assessment of each resident is completed for diagnostic clarification. Based on the assessment’s results, a resident’s substance use disorder (i.e., abuse, dependence, or a combination of both) is clearly defined, with treatment then matched to level of use. Furthermore, this assessment provides cognitive, emotional, behavioral and personality information that is essential in determining the most appropriate interventions for the resident.

Particularly with adolescents, who are most often not internally motivated for treatment upon admission and who are typically in the precontemplation stage of change, acknowledging powerlessness in terms of use or genuinely considering sobriety are often not realistic starting points for treatment. Utilizing a harm reduction model promotes the development of internal motivation for change while lessening opportunities for power struggles, which adolescents engage in frequently and which can sidetrack treatment.

The evidence-based harm reduction model utilized at Rushford at Stonegate is The Seven Challenges, which has been shown to be particularly effective in reducing mental health and trauma-related symptoms.² The Seven Challenges program is a holistic approach to adolescent substance use that addresses not only use, but also reasons for using. It incorporates cognitive, emotional and health decision-making processes that promote self-efficacy by encouraging teens to think for themselves and to make their own informed decisions.

There is a strong emphasis on teaching social, psychological and emotional life skills that enable adolescents to learn new adaptive ways to cope with their stressors and meet their needs. Through individual therapy, group therapy and journaling, teens have the opportunity to learn skills and develop resources in areas such as problem solving, communication, anger management, social/relational, self-control, thinking, relaxation, and stress reduction.

These are the tenets of The Seven Challenges:

1. We decided to open up and talk honestly about ourselves and about alcohol and other drugs.
2. We looked at what we liked about alcohol and other drugs, and why we were using them.
3. We looked at our use of alcohol and other drugs to see if it had caused harm, or could cause harm.
4. We looked at our responsibility and the responsibility of others for our problems.
5. We thought about where we seemed to be headed, where we wanted to go, and what we wanted to accomplish.
6. We made thoughtful decisions about our lives and about our use of alcohol and other drugs.
7. We followed through on our decisions about our lives and drug use. If we saw problems, we went back to earlier challenges and mastered them.

The language of The Seven Challenges provides opportunities for more collaborative work between residents and staff from the start of treatment. The initial expectation is openness and honesty, which is reinforced for all residents regardless of level of use. This model facilitates less resistive interactions because it puts the resident in the role of an active decision-maker. A balance between providing structure, boundaries and limitations while still allowing the resident to feel that he has a significant influence over the course of his treatment facilitates a trusting and open therapeutic alliance.

That being said, while some of the language and philosophy of The Seven Challenges is still used for residents who meet criteria for substance dependence (particularly Challenge One), a more direct and clear message about abstinence is necessary in these cases because addicted adolescents have a severely compromised capacity for healthy decision-making. The changes in their brains have already resulted in an inability to control impulses.

The abstinence-based 12-Step model that was initially created by the founders of Alcoholics Anonymous (AA) has since been modified and applied to numerous other addictive and compulsive problematic behaviors. The 12 Steps are focused principles that guide clients with addictions toward sobriety and recovery with the support of others in recovery as well as family, friends, treatment providers and others. The ultimate goal of the 12 Steps is to resolve the destructive cycle of addiction and achieve a balanced and healthy physical, psychological and spiritual life by providing the client with a lifelong program and network of support.

The 12-Step process involves the following (as summarized by the American Psychological Association):

• Admitting that one cannot control one’s addiction or compulsion;
• Recognizing a higher power that can give strength;
• Examining past errors with the help of a sponsor;
• Making amends for these errors;
• Learning to live a new life with a new code of behavior; and
• Helping others who suffer from the same addictions or compulsions.

Abstinence necessary

At Rushford at Stonegate, for adolescents with substance dependence disorders, the emphasis is on the necessity of abstinence as both a short- and long-term goal. While often highly resistant, particularly in the initial stages of treatment, addicted adolescents are given the message that immediate abstinence is essential because doing otherwise would pose significant safety risks.

Furthermore, addiction interferes with the development of a genuine therapeutic relationship, via the capacity to give and receive mutual aid and interpersonal support. Associated with the alterations in a person’s neurophysiology, addiction involves an intense relationship between the person and the substance that gradually replaces the regulating, soothing and sustaining functions provided by human relationships.

As Flores persuasively argues, addiction is an attachment disorder and in order for the individual to develop relationships with others, the addiction to the substance must be relinquished. “Before chemically dependent individuals can become attached to treatment, they must first get detached from the object of their addiction.”³

While it is clear that addicted residents require exposure to abstinence-based mutual aid groups such as AA, all Rushford at Stonegate residents attend meetings at least twice weekly because it is not clear which non-addicted individuals might reach the level of dependence in the future. Therefore, it is essential for all residents to be exposed to all recovery resources available.

To increase engagement, these groups are run by a recovery specialist who works primarily with adolescents and young adults. Likewise, teen and young adult speakers are often brought into the meetings, and residents can attend a young adults’ AA meeting in a nearby community.

Integrating harm reduction and abstinence-based treatments at Rushford at Stonegate provides residents with developmentally informed interventions (designed for a co-occurring population) synthesized with traditional substance use treatment practices. While the goal for all residents is abstinence from all addictive substances, the means to that end can be more flexible than is the case in traditional abstinence-based programs that necessitate declaration of addiction as evidence of treatment readiness. This approach reduces resistance, increases engagement, and facilitates openness and trust, as well as enhancing opportunities for a more positive treatment experience.

Francis Bartolomeo, PhD, is Vice President of Child and Adolescent Services at the Rushford addiction and mental health treatment organization in Connecticut. His e-mail address is Fbartolomeo@rushford.org. Jennifer Richards, PsyD, is Clinical Director at Rushford at Stonegate.

References

1. Futterman R, Lorente M, Silverman S. Integrating harm reduction and abstinence-based substance abuse treatment in the public sector. Subst Abus 2004;25:3-7.
2. Stevens SJ, Schwebel R, Ruiz B. The Seven Challenges: an effective treatment for adolescents with co-occurring substance abuse and mental health problems. J Soc Work Prac Addictions 2007;7:29-49.
3. Flores PJ. Group Psychotherapy With Addicted Populations: An Integration of Twelve-Step and Psychodynamic Theory (3rd ed.). New York City: The Haworth Press; 2007.