Treatment of Adolescents
with Substance Use Disorders
Chapter 3 -- General Program Characteristics
The previous chapter examined the range of substance use disorders and related problems seen in adolescents. The chapter then applied those factors to treatment placement decisions. This chapter discusses how individual program components can best meet the needs of adolescent clients. Program design and administration, treatment components, client services, and a program's collaborative relationships are important considerations for practitioners or other staff members who are treating adolescents or referring them to an outpatient treatment setting.
Scope and Approach
A program's design, policy, evaluation, and legal approach are shaped by its underlying philosophies--the core values and beliefs from which treatment decisions arise. Mapping out these program features can provide a strong and flexible framework for providing services that are implemented smoothly and effectively and yet are individualized to meet each client's needs. Much of this information shows up in a program's policy and procedures manual.
Although a program's funding and scope limit the number and depth of treatment components a program can provide, it is vital that the most critical components be identified and implemented with skill and timeliness. In addition, expectations for successfully completing treatment should be as clear and as objective as possible.
Policies and Procedures Manual
A program's policies and procedures manual provides guidelines for program operation. It also serves as a reference book for Federal, State, and local laws and regulations and for requirements for contract compliance. State licensing requirements may also include obligatory standards about what goes in a policy and procedures manual. Both the program staff and clients are protected by these regulations, which may include the following:
- A program mission statement identifying underlying program principles, including the program's commitment to a drug-free workplace
- Confidentiality procedures for clients as well as the staff
- Documentation guidelines and requirements for client charts, including reporting requirements for sexual and physical abuse and suicidal and violent behavior
- Personnel policies that describe
In addition, HIV guidelines and staff training should describe the universal precautions recommended by the Centers for Disease Control and Prevention, specify who should know the HIV status of clients and family members, and outline the policies and procedures for HIV testing of clients and staff members. Programs may wish to designate a staff person as the AIDS trainer. This training helps to raise awareness of the HIV-related needs and concerns of adolescents. Also, guidelines should address precautions about hepatitis B and C and tuberculosis. Some strains of hepatitis are easily transmitted and may be more prevalent than HIV in certain communities. Hepatitis B vaccinations may be considered for at-risk staff members with significant client contact.
Staffing
Staffing decisions are best made with attention to program needs, job descriptions, and educational and experiential requirements for each position. It also must be determined which services will be provided on site by program personnel and which are to be provided by arrangement with an external agency, program, or professional. If volunteers or interns are to be an integral part of the program, specific policies must be established regarding their supervision, training, and responsibilities.
Staff members should represent the cultural diversity of the program's client population. In addition, the facility's forms, books, videos, and other materials should reflect the culture and language of the clientele. Innovative and intensive continuing education, staff development, and outreach efforts during staff recruitment may be needed to improve cultural competence among staff. If a significant part of the client population is non-English-speaking, at least one staff member should be bilingual and bicultural. Cultural differences should be addressed in clinical staff meetings, through interagency collaborations, and at all levels of the organization, with the goal of enhancing cultural sensitivity and cultural competence. For individuals with disabilities, the Americans With Disabilities Act of 1990 requires treatment facilities to be accessible to all clients, which may mean having a sign language interpreter and other specially trained personnel on staff. For more information on treating people with disabilities and coexisting disorders, see TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT, 1998).
Core Staff
The type of program and the range of services offered within a program determine treatment staffing patterns. The following positions should comprise a core staff:
- Program or clinical supervisor
- Substance use disorder counselors
- Therapists (preferably at a master's level with a certification in substance abuse treatment)
The essential roles of core staff include
- Intake
- Screening
- Assessment (including a cultural assessment)
- Case management, including treatment planning and crisis intervention
- Substance use disorder treatment (individual, group, family)
- Providing specialized education on topics such as understanding substance use, HIV infection and AIDS, and other sexually transmitted diseases (STDs)
- Planning continuing care and treatment
- Record keeping and report writing
Optional Staff
As the intensity of the treatment increases, programs may require additional personnel. These professionals may be hired as part-time staff members or as consultants, or they may be provided by contract or through referral. They include:
- Psychiatrists
- Pediatricians, adolescent medicine specialists, internal medicine specialists, and/or family practitioners
- Psychologists
- Nurses
- Recreational therapists (leading activities in art, music, drama, wilderness outings, etc.)
- Occupational therapists
- Disabilities specialists, including sign language interpreters
- Outreach workers
- Home intervention workers
- Continuing care workers
- Cultural advisors or spiritual leaders
- Students, interns, and fellows (from local colleges and universities)
- Vocational specialists
- Case managers
Skills Development
The complexities of an adolescent's needs and concerns require that the clinical staff be supervised. However, high-level skill or expertise may not be necessary for all staff members in all areas. Most important is regularly scheduled training that occurs periodically throughout the year. This is greatly preferable to ad hoc training presented to address crises or acute situations. Training on specialty topics should be available in the following areas:
- Changes in diagnostic criteria for substance use disorders (e.g., DSM-IV criteria)
- New substance use disorder treatment approaches specific to adolescents and their families
- Family dynamics and family therapy
- Adolescent growth and development
- Sexual and physical abuse
- Gender issues, including gender and sexual identities (e.g., gay, lesbian, transgender)
- Mental health problems (particularly depression, anxiety disorders, and conduct disorders)
- Awareness of different cultural and ethnic values
- Recreational and prosocial activities
- Psychopharmacology
- Group dynamics and group therapy
- Suicidal behavior
- Grief and loss
- Referral and community resources
- Management of oppositional and violent behaviors
- Cognitive impairments (learning disabilities, cognitive disorders, and organic mental disorders)
- Legal matters (custody and juvenile justice concerns, child abuse and neglect reporting requirements, and duty-to-warn issues)
- Treatment planning and documentation
- HIV/AIDS
- Other health matters (STDs, tuberculosis, hepatitis, nutrition)
- Gangs
- Drug dealing
Staff Members in Recovery
Treatment programs often use recovering substance abusers as staff members. Staff members who are themselves in recovery can offer unique hope, role modeling, and insight into dependency, addiction, and recovery. When recovering individuals are hired, they should have the same level of expertise and training required of other staff members in the same position. Recovering individuals must have clear evidence of at least 2 to 5 years of recovery demonstrated by regular attendance at 12-Step meetings, a current sponsor, and continuous abstinence from substances other than those prescribed by a physician.
Certification and Credentials
Each State has different requirements for the certification of substance abuse counselors. Certification is available in many disciplines; for example, a nurse can be certified in chemical dependency, and a physician can become a certified addictions specialist. Records documenting these credentials are necessary. Programs should encourage all staff members to become certified and support their continuing education efforts to enhance their clinical competence in their specialty.
Supervision and Evaluation
A supervisory review of each staff member's performance should be conducted on a regular basis. Opportunities for self-evaluation and feedback from other staff and team members can be included in the evaluation process. The program's manual on policies and procedures should specify how the program deals with staff turnover, burnout, relapse, and related staff problems, as well as specific procedures for staff reviews.
Supervision should include training staff on program procedures and policies, developing clinical skills, monitoring performance and providing feedback, identifying clinical limitations, addressing transference and countertransference (such as relationships and identification between the adolescent and treatment personnel), and dealing with staff concerns.
Perspectives on Counseling Youth
Understanding how adolescents perceive and react to treatment is crucial in developing appropriate counseling techniques to address their substance use. Treating an adolescent like an adult will likely result in failure--counseling adolescents requires sensitive yet firm approaches. An adolescent treatment program should have explicit and impartially administered standards for behavior. It should emphasize treatment of every participant in a personal, respectful, and hopeful manner. The program staff should maintain an optimistic tone and be dedicated to serving and helping its clients, while exercising authority without seeming authoritarian. The staff should also ensure that every participant is protected from possible harassment, such as teasing and hazing, by other program clients. When youths do not abide by the treatment program guidelines, they must be held responsible for their conduct, but in a manner that avoids a confrontational style or indicators of mistrust. It is also important that youth be helped in fulfilling their responsibilities in a way that would typically be inappropriate for adults. For example, if an adolescent does not show up on time for an outpatient program, he should be called immediately and reminded to attend.
Program Components
Many adolescent treatment programs, regardless of their therapeutic orientation, include significant shared components, some of which are described below. The level of intensity of these components will vary considerably in outpatient and residential treatment.
Orientation
This initial stage in treatment is very important to the adolescent. Many new activities may be threatening to the adolescent, and coming into treatment can intensify feelings of fear and self-consciousness. Moreover, adolescents frequently have incomplete and inaccurate information about the nature of substance use disorders and treatment programs. The client may have heard that very negative things happen in treatment and that "people really get on your case." The awkwardness experienced by adolescents may also be intensified. During adolescence, many situations can increase a young person's anxiety level. Anxiety can be acted out in many negative ways, including leaving or running away from the program. Sometimes, the acting-out behavior is so disruptive that the client may have to be discharged by the staff. Thus, it is important that the orientation to treatment be structured to provide relief from anxiety.
One main component of orientation is explaining to adolescents what treatment is, as well as what it is not, in a nonconfrontational style and tone. If the youth has a mistaken notion about the nature of treatment, the chances for treatment success may be lowered. Young people come into treatment with many different expectations. It will help the adolescent to know the meanings of such terms as chemical dependency, expectations, and unmanageableness. But definitions must be clear and not too abstract, given that some adolescents may be unable to grasp complex concepts.
Orientation also provides an opportunity to clarify the adolescent's role. Videos of activities to be experienced in treatment can be shown. Orientation should include the concept of program expectations. This term is preferable to the term rules, which implies staff dictates or commands (Winters and Schiks, 1989). Having expectations implies ownership by the client and promotes responsibility from him. Communication of essential principles and expectations can start during orientation and continue throughout the treatment process.
Daily Scheduled Activities
Most adolescents who require treatment for substance use disorders have been preoccupied with the use of substances to the exclusion of participation in positive recreational activities and the development of basic living skills. When the substance use is removed, they may not know how to use their time appropriately. A prescribed daily schedule of school, chores, homework, and especially recreation can significantly help with this relearning process. In outpatient programs, staff members can work with adolescents and their families to schedule activities for the client during the hours away from treatment; in residential programs, scheduling can be more elaborate. A full schedule with many different group activities has been shown to work well with adolescents (Winters and Schiks, 1989).
Adolescents who have centered their leisure time on the use of substances may resist learning new skills and often equate staying clean with boredom. Youths who engage in thrill-seeking behaviors by using rock cocaine seem especially susceptible to anhedonia, an inability to experience pleasure, because of the boredom that sets in afterward. Encouraging the adolescent client to take advantage of community recreational resources and to develop socially appropriate recreational habits will help ensure that she remains sober following treatment. Adolescent treatment programs can provide many recreational opportunities to their clients with relatively little expense. For example, a program might establish an athletic period during which it takes groups of youths to the local "Y" to play basketball. Chess, ping pong, computer games, and other sports and games can be provided at the treatment site.
Peer Monitoring
Given the important influence of peers on an adolescent's behavior and attitudes, it stands to reason that pressure from peers often keeps the client from achieving treatment goals. Although this pressure occurs in social times rather than within structured program activities, it must be addressed during treatment. Group therapy can help the client build the strength needed to override peer pressure and harness the influence of the peer group in a positive manner. In a process guided by the clinician, clients can receive constructive feedback about their progress from their peers. The group can serve as an important source for addressing the client's denial about his substance use disorder, as well as promote positive behavioral changes. In addition, peers can indirectly influence change by way of clients' learning vicariously through others' stories and interactions (Stinchfield et al., 1994). When denial is strong, peer monitoring can be a relatively nonthreatening form of confrontation.
Conflict Resolution
Conflicts often arise among young clients or between clients and staff members. The treatment staff should take a proactive stance to resolve such conflicts. This may entail having extra staff meetings or addressing these issues directly in team meetings. How the conflict is dealt with is critical. If staff members take an authoritarian approach, the conflicts may escalate, resulting in damaged rapport and a retreat from the treatment process.
Power struggles between a youth and a counselor can arise from the client's inability or unwillingness to meet program expectations. They also often arise when the staff is not trained in how to work with adolescents. When a youth is unable to meet program expectations, modifications in the treatment plan to better suit the client's abilities are desirable. It is important in power struggles to keep the focus on what the client can reasonably achieve rather than on staff policies. If it appears that numerous program expectations have to be modified for the client, this may signify that the program is not appropriate for that individual. In such cases, the client may have to be referred to a different level of care or to another treatment program.
For cases in which the client seems able to meet the program's expectations but does not do so, the clinician should directly address what is impeding the client's participation. It is most useful to encourage a resistant adolescent by telling her that she has the capabilities but is not working up to her level. This positive approach may help avoid unnecessary power struggles. An unwilling client may need the attention of staff members who are skilled in implementing motivational techniques such as building therapeutic rapport and in identifying and addressing specific sources of poor motivation, such as the client's having a learning problem, feeling shame or guilt about having his problems with substances come to light, and experiencing social discomfort by virtue of being in a new environment.
Client Contracts
Entering into a behavioral contract, including a substance-free contract, with an adolescent is a counseling tool that can help a provider identify the current level of the adolescent's functioning and developmental markers, providing a baseline from which to periodically monitor change. Contracts should include the following:
- Specific treatment goals organized around specific client target behaviors
- Concrete descriptions of the consequences to the client if the contract is not followed and the rewards if the contract is followed
- Specific outlining of situations to which the contract applies
- The time frame during which the contract is active
- Options regarding contract revisions
- A written reminder of boundaries and expectations
The contract should be composed and signed by both the client and the primary counselor and copies distributed to both parties. By involving the client in the process, the importance of the goals is emphasized, and a commitment to the plan is asked of the client and the therapist. Contracting provides a clear and concrete set of expectations that are mutually acceptable to both the client and counselor. It helps hold the client accountable for her behavior and undercuts manipulation. Some counselors also have the adolescent's family sign the contract, which communicates to the client that her family is also committed to the treatment process.
Contracts are especially useful to adolescents because they give them a sense of control in going through treatment and a degree of personal investment in their well-being, both of which are important to teenagers who have difficulties with authority or who are struggling to establish an identity. Moreover, contracts may represent the first time an adult has taken real interest in them. A successfully completed contract can give an adolescent a sense of self-fulfillment and responsibility that will be valuable after treatment is finished.
It is important to avoid written contracts that are inflexible and that pose unreasonable expectations for teenagers whom staff members would like to exclude from treatment programs.
Clients who enter into a contract too quickly may come to believe that it is a form of coercion on the part of the counselor. Contracts should be made in the context of collaboration between the adolescent and counselor, in which clients have a role in defining problems, goals, and approaches that will be the focus of their individual treatment.
Schooling
Some States mandate that adolescents receive several hours of classroom schooling while in treatment, particularly if they are receiving residential care or day-long outpatient care. Helping adolescents have a successful experience in the classroom is one of the most important factors in their recovery. Regardless of whether the schooling is provided on site (by the program or through homebound public teachers) or off site (in public settings), the educational program must be fully integrated into the adolescent's clinical program. This is best accomplished when the teaching staff members are considered part of the treatment staff and when the behavioral program is extended into the classroom, as occurs in many residential programs. If adolescents attend local public schools, it is desirable to have a dedicated liaison at the school who can attend treatment team meetings at the program.
Educational activities generally focus on substance use disorders and recovery, as well as on basic school subjects. Conducting educational activities with this age group can be challenging. It is a common observation among treatment providers that many adolescents suffer from learning disabilities. Staff members must be able to deal with reading and attention span problems by modifying traditional education strategies and techniques. For example, group exercises in which the clients are required to read aloud may not be very productive. An alternative is to play an audiotape while adolescents follow along in a book; another is to assign reading to a designated reader group composed of clients who enjoy reading and can read well aloud.
Testing can be done to determine the client's reading ability and to rule out learning disabilities. Testing should also include an eye exam and an evaluation for blurred vision as a side effect of medications, because poor vision can confound test results. Special reading materials should be available for clients with reading and attention span problems. Another approach is to give lectures that allow for interaction among the clients in a group. The power of the personal story can also be a powerful teaching tool, particularly when an experienced patient recounts her experiences.
Questions to consider in developing a school program include the following:
- What are reasonable academic expectations for the adolescent client? By obtaining the client's school records, staff members can gauge appropriate educational goals.
- What criteria and procedures will be used to determine whether a client has special educational needs?
- To whom should the client be referred for specialized educational testing?
- What liaisons with the client's school can be developed? Issues that can be discussed include receiving appropriate academic credit for class work taken as part of the treatment program and re-enrollment planning.
- How are the client's treatment and educational needs coordinated, and if necessary, how will these needs be coordinated with juvenile justice and child welfare systems?
It is important to emphasize that schools are mandated to identify youngsters with learning disabilities and to develop an individualized education plan for each student with disabilities.
All staff members working with adolescents must be sensitive to their educational needs. Staff members should advocate for their clients' continued participation in school.
Vocational Training
Career planning--that is, education about different career possibilities--is an important intervention for adolescents and should be a part of a treatment program's clinical plan. For example, having people in various professions come to a program and talk about their work and their careers is often of interest to adolescent clients. Other appropriate interventions include prevocational training (e.g., a program that emphasizes coming to work on time, the appropriate etiquette for interacting with a boss or supervisor, acting in the interest of an employer when on the job) and teaching job-finding skills (e.g., how to find a job, how to prepare a r_sum_, how to speak at an interview).
Without these skills, many youths may be more likely to support themselves through illegal activities and would be more prone to relapse.
Because many outpatient programs cannot directly address the vocational needs of their clients--often because they lack vocational training resources and specialists--it is important to attempt to develop collaborative agreements with local vocational programs.
Treatment Planning
A treatment plan should be developed by the primary therapists or treatment team in concert with the client, family, family collaterals, and, when possible, representatives of the referring agency. Engaging both the client and family in the treatment process can promote their willingness to participate in the actual intervention. All of these parties must obey the Federal confidentiality regulations (see Chapter 8). The treatment plan should be comprehensive, specific, and objective so that progress can be measured. Naturally, the plan should address the environmental factors that may have contributed to the youth's substance use disorder and that could be a hindrance to recovery. At a minimum, a treatment plan should identify the following:
- Target problems of the client and the family, including substance use and psychosocial, medical, and possible psychiatric disorders
- Goals that help clients recognize their involvement with substances and acknowledge responsibility for the problems resulting from substance use and that take into account what the adolescent wants to accomplish
- Objectives that are realistic and measurable steps for achieving each goal
- Time frames for the achievement of the stated objectives
- Appropriate interventions, that is, treatment strategies and services that are needed to achieve the objectives
- Assessment methods for measuring the extent to which goals, objectives, and interventions are fulfilled
- Educational, legal, and external support systems
The specified treatment strategies and services should include the identification of the persons who will be providing treatment, an expected timetable for achieving the objectives, the date the treatment plan will be reviewed, and where treatment is to take place (Beck et al., 1993; Berg, 1991). The treatment plan should be subject to frequent reassessments to determine whether the client is making therapeutic progress. If progress is not being made, the client, family, therapist, and key interested players should examine whether the therapist's goals and the client's goals match.
Linkages to the Community
Treatment programs must work closely with the other entities that are involved in the treatment of adolescents. Programs whose clients are often involved in multiple agencies (especially school systems, child welfare, and juvenile justice agencies) should write interagency agreements, also called memoranda of understanding, with other involved agencies. The agreements should describe payment policies, funding problems, mutual goals for clients, and intra- and interagency contracts. Moreover, guidelines for confidentiality must be established, and discussions should focus on potential problems or key concerns for which different agencies may have different policies (such as protocols for a student who is found to be carrying drugs).
In addition to interagency memoranda of understanding, it is important to have an established practice of exchanging signed releases of information from each shared client, insofar as the client is willing to agree to share information and sign releases, so that the involved staff members can more freely exchange confidential information about the client's progress and difficulties (see Chapter 8).
Program managers should encourage and support staff members' involvement in community activities, a task that often goes "above and beyond" a person's official job description or title. Outpatient programs often must rely on staff members from other community programs to complement their services or to provide staff training. Community involvement by the program staff can empower the community to address local problems such as gangs or territorial issues.
Recovering individuals in the community can serve as valuable role models and mentors for adolescents in treatment. Adolescents particularly need adults to whom they can relate and with whom they can identify. These may be young recovering adults who have achieved or are working toward their educational goals; who are doing well in their profession or employment, perhaps owning their own business; and who have generally been able to succeed despite their history of substance use. These individuals can offer advice, assistance, and support in tasks such as preparing r_sum_s, helping with schoolwork, or selecting and applying to colleges.
Also key are networking with community services, understanding the community's reaction to the program's presence, and establishing a community advisory board. It is advisable to include recovering adolescent clients on the advisory board. Building a broad community base can enhance the program's opportunity to provide effective treatment for youth in the community. It cannot be overstated that a commitment by the program to community involvement is vital for the success of an adolescent outpatient treatment program.
Program Evaluation
In recent years, there has been modest progress in addressing the question of whether adolescents improve after substance use disorder treatment (Catalano et al., 1990-1991; Friedman et al., 1986, 1994; Hoffmann et al., 1987, 1993). Continuing assessment of program efficacy can provide valuable information on which areas of a treatment program are functioning smoothly and which areas require modification. External licensing, accreditation, and funding agencies may carry out such an evaluation, often for the purpose of monitoring compliance with Federal, State, and private agency regulations. Alternatively, evaluation may be carried out internally by staff and clients. The value of such assessment depends more on the measures used than on whether it is accomplished externally or internally.
All too frequently, program evaluation is based on the number of clients seen, the maintenance of a desired census level, or adherence to regulations or protocols without regard to outcome measures. Many programs of high quality do not document their effectiveness in terms of client retention, posttreatment functioning, and use of aftercare services, for example. Although the cost of care, efficiency in treatment, provision of categorical services, and adherence to regulations are certainly important, the true worth of a treatment program must be measured by the success of its clients.
When evaluations involve making comparisons between programs, differences among clients must be considered. For example, some programs will not accept clients with coexisting disorders and will inevitably produce better "outcomes" than programs that admit regardless of coexisting disorders.
Evaluation of success must be ongoing and must apply both to adolescent clients who complete treatment and to those who left care prior to discharge. It is the obligation of the treatment program to provide for the continuing assessment of each client's progress, although obtaining accurate information on an adolescent's maintenance of abstinence and success in other life skills may be difficult, expensive, and time consuming. Such difficulties are pervasive within the field of substance use disorder treatment and remain an obstacle to assessing the efficacy of a specific program and to comparing the effectiveness of different treatment approaches. Nevertheless, each program has an obligation to monitor progress of the client during treatment and attempt to characterize the long-term success or failure of adolescents discharged from its care. The knowledge gained through these processes should be used to refine the treatment program.
Monitoring the adolescent's progress during treatment typically includes receiving feedback from members of the treatment team, obtaining reports directly from the adolescent, and getting reports and feedback from family, school, and employers. Some evaluations include use of urinalysis and Breathalyzer_ results to provide a validity check against self-reports. For a complete discussion of the measurement of posttreatment outcomes, readers should refer to TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (CSAT, 1995a).
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 99-3283
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Teens
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Teen
Alcohol Use
Alcohol
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Anabolic
Steroids
Effective
Parenting
Fostering
Responsibility
Fostering
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Problem
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Adolescent
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