These days just making the journey from adolescence to adulthood is hard enough. Mix in alcoholism and other addictions and it can seem impossible. Despite this, many programs have heroically attempted to treat adolescent addicts, often with disappointing outcomes. Whereas treatment in general reduces drug use by 21 per cent overall, recent SAMHSA studies found that treatment for adolescents actually increased their chemical use by an average of 13 per cent! (SAMHSA, 1993). To exacerbate these dismal findings, adolescent programs for addiction require longer stays, a higher staff to patient ratio and cost significantly more then the familiar 28 day program (NDATUS, 1989).
The news is not all bad, however. Although treatment for adolescents doesn't appear to give the desired results, the ones who do find their way to recovery from addiction are more likely to have gone through treatment than not. Therefore it becomes our job as treatment professionals to identify what assumptions don't work in the old model of adolescent treatment, what does work, and learn how to treat an adolescent in a setting that is most likely to lead him or her to long-term abstinence from mind affecting chemicals. The difficulties with the old model of adolescent addiction treatment have emerged with time and experience. They include:
- Emphasis on family therapy as a means to change addictive behavior
- A tendency in the staff on adolescent only units to treat adolescent addicts differently then older age addicts in ways that are counterindicative for abstinence
- A homogeneous treatment setting that aggregates problem behavior
Too Much Emphasis on Family Therapy
The first problem with our assumptions in treating adolescents is the unrelenting focus on the parents and family structure as the key to recovery. Even though family participation in treatment has never really been able to predict continued abstinence (Fiorentine and Anglin, 1996), reviews of studies do state that family involvement in treatment for substance abuse is effective (Diamond, Serrano, Dicky, and Sonis, 1996). Yet, an analysis of the reviews reveal studies that are not well controlled and that most findings are correlational in nature. They state findings that say things like: when the family conflict is reduced, the drug addict uses less drugs. One could just as easily say that when the user uses less, family conflict decreases. It's a mistake to base treatment on weak correlations like this. McCrady makes a great point when he explains that well controlled research in this area is scarce and "there are notable discrepancies between the popularity of clinical practices and the empirical bases of practice" in family-involved alcoholism treatment (McCrady, 1989).
Not Enough Emphasis on Abstinence
Another reason for the failure of adolescent only centers may be a lack of emphasis on total abstinence. Even though it is known that long-term abstinence is associated with 12-step meeting attendance in the first year following treatment (Thurstin, Alfano, and Nervivano, 1987), staff members on adolescent units tend to recommend fewer 12 step meetings to their younger clients then they do with adult clients. They also have an average of only 23 per cent recovering staff as compared to multigenerational units that have 50 to 60 per cent of staff in recovery (Marshall and Marshall, 1994). This may in part explain the lack of emphasis on 12 step meeting attendance because recovered alcoholic counselors also recommend significantly more 12 step meetings for clients then nonalcoholic counselors. In addition, adolescent treatment is less likely to use abstinence as a measure of treatment success then multigeneraltional units. Presumably, abstinence may not be their treatment goal (Rush, 1986).
High Risk Youth are Vulnerable to Peer Aggregation
The third and most important reason that the old model and its inherent assumptions doesn't work well is that it places a young person in a peer environment that makes it practically impossible to recover. This is the single most important point to understand in treating adolescents. Kids are socialized by their peer groups--not by their parents and not by the professional. They gain their attitudes, behavior, likes and dislikes, and propensity for change from their peers. This has startlingly strong therapeutic implications.
- Whatever their reference group (also called psychological group, peer group, subculture, or even more informally neighborhood and gang), what they think of each other is vastly more important to them than what their counselor thinks of them (Raniseski and Sigelman, 1992).
- This activates the 'group contrast effect' which means they define themselves by their differences to other groups. In society, adults verses kids is an obvious and natural contrast (Harris, 1998). In adolescent treatment centers it becomes exacerbated as young people square themselves off against the adult staff in an "us" verses "them" effect.
- There is not as much to peer pressure as there is to peer preference. Young people want to be like their peers and not like other groups. In institutional settings adolescent peers provide a rate of reinforcement of 9 to 1, compared with adult staff (Buehler, Patterson, and Furniss, 1966), suggesting that staff messages are unlikely to have any permanent influence within an adolescent peer-based treatment setting. It has been shown that peer aggregation can inadvertently reinforce problem behavior and increase drug use (Dishion, McCord, and Poulin, 1999).
- Adolescent behavior is context specific. Kids will act one way with their parents, another way with staff, and another way with each other. It is the way they act with each other that will be carried into their adult lives leaving most other influences behind (Harris, 1998).
By placing young people in a contextual framework of drug addicted maladjusted same age peers (that will, by definition, become their reference group), the only way to embrace recovery within this context, would be to be abnormal. They would have to go against the normal and innately powerful process of group socialization to align themselves with the staff. The consequences would be the negative judgment of their peers and non assimilation into the group they prefer. Although not unheard of, kids don't turn their back on their reference group very often.
Components for Motivating the Adolescent
Motivating an adolescent to want recovery has several important components:
- First, they must accept their addiction and responsibility for dealing with their addiction. Self-responsibility has a poor chance of taking root in a center that focuses on family therapy as a primary means of change. When an addiction therapist concentrates on the family, responsibility for change is largely shifted from the individual who uses to the family (Rechelt and Christensen, 1990), leaving the adolescent blaming his parents covertly if not overtly, for his/her condition. This neutralizes self-responsibility as a means to healthy choices (i.e. "Once the family straightens out I won't have a drug problem.").
New Treatment Practice: Rather then using family therapy as if the parents are collaborators in the disease process, use them as treatment facilitators. Enlist their help to carry the principles taught to their child back to the home. Begin a program that teaches the parent the basics of the disease and recovery process and suggest actions they can take to extend treatment in the home environment. Using parents as co-treatment facilitators instead of "treating them for a disease" will decrease defensiveness and guilt while imparting healthy parenting skills. In addition it will take away the adolescent's venue of blaming parents for their drug use and allow the adolescent to retain primary responsibility for his/her own choices.
- Second, if abstinence is the goal of treatment, getting the young person well socialized into 12 step groups (or other support groups that have proven effective) is highly important for recovery to be maintained.
New Treatment Practice: Form a pool of approved volunteer sponsors from community support groups and have the young client pick a temporary sponsor from your list. Assign regular meetings with their sponsor (similar to mentoring programs in high school) as a component of treatment. Arrange to take clients to 12-Step meetings in the community, preferably ones their volunteer sponsor goes to. Teach them 12 Step Club etiquette and have them join a club of their choice. Don't just suggest meetings post treatment. Make socializing your young client into community support groups an intricate part of the treatment process. This is what will sustain long-term abstinence.
- Last, they must identify with a reference group that is working toward recovery and will reward group members for healthy choices. This cannot be done in an adolescent only center. Changing the reference group they identify with will change their whole life.
New Treatment Practice: Place adolescents in multigenerational settings--in-patient, out-patient, or day care. Keep the ratio at 20%. Limit your client population to no more than one client under the age of 18 for four over. The peer group (reference group) of your young client does not have to be same age cohorts. Adolescents are on the brink of adulthood anyway and can accept a new, older reference group if presented in a manner that includes them as an emerging adult. The new group must be salient so that the group contrast effect makes them want to be a member in good standing. The 'us' verses 'them' effect will still take place only the 'us' now becomes 'us in recovery from addiction to mind affecting chemicals' and the 'them' becomes the 'unfortunate people still using and not understanding the disease of addiction and its implications.' Adolescents who receive treatment from a multigenerational setting as compared to those who receive treatment from an adolescent only setting are five times more likely to remain abstinent post treatment (Marshall and Marshall, 1993).
Treating the young person in the same milieu that we treat our older clients is not easy to do when we have been taught for years that adolescents have different family and developmental issues that can only be addressed in segregated settings. Letting go of the assumption that parent's and therapist's affects are not directly related to how our young clients behave and how their attitudes are formed is letting go of what we've been taught for 25 years. We all want to believe that if we are skilled enough, motivating enough, and change the structure of our young client's home environment enough that they will skip happily into recovery. Now we find, that contrary to our assumptions of how adolescent-only treatment should work, it is not us, per se, not even the parents per se, but the reference group that will make the difference in attitude, acceptance of treatment, and embracing recovery.
You want clean and sober adolescents?
Although the professional may not be able to influence most adolescents in adolescent only treatment settings, they can influence the dynamics that influence the adolescent by changing their group of reference. You want clean and sober adolescents? Don't treat them like adolescents. Treat them like recovering young adults and place them in a setting where their cohorts are adults/young adults in recovery. They are going to make the transition anyway, in a very short time if they haven't already gone from adolescence to young adulthood. You're just giving the process a little boost so they live long enough to grow up.
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