Drug and Alcohol Drug and Alcohol Services for Services for Adolescents Adolescents Presented by Presented by Howard Dounn Howard Dounn Phoenix House. Lake View Terrace Phoenix House. Lake View Terrace
Dec 29, 2015
Drug and Alcohol Services Drug and Alcohol Services for Adolescentsfor Adolescents
Presented byPresented by
Howard DounnHoward Dounn
Phoenix House. Lake View Phoenix House. Lake View TerraceTerrace
SUD Impedes Development in SUD Impedes Development in Adolescent Substance AbusersAdolescent Substance Abusers
• Coping skills• Social/interpersonal skills• Communication skills• Identity, values consolidation• Affect identification/regulation• Self-efficacy and external locus control• Pro-social network & role models
PrevalencePrevalence
Drug abuse/dependence: 3-9%
Alcohol abuse/dependence: 5-8%
Higher prevalence SUD reported if in
juvenile justice system
Higher SUD (60-80%) if psychiatric
disorder
Only 1 in 10 with SUD receive treatment,
of those that do, only 25% receive enough
Methamphetamine UseMethamphetamine Use • methamphetamine use and abuse (MA) is increasing
• 1997 - annual use estimated at 2.3% amongst 12th graders – in 2003 risen to 13%
• treatment admissions for MA in CA have doubled since 1992-2002, total admissions have only increased 17%
• cognitive impairment, auditory hallucinations, psychological dysfunction, and suicidal impulses
• chronic methamphetamine use can permanently alter brain & cognitive functioning (exposure & amount)
Characteristics of Youth Seeking Characteristics of Youth Seeking Treatment for MA in Los AngelesTreatment for MA in Los Angeles• More whites and Latinos using methamphetamine than
other groups • Fastest growth in rates of MA among older adolescent
females compared with males • Alcohol and marijuana initiation patterns tended to occur
earlier in MA• Teens are coming from drug saturated environments
with exposure to parental substance abuse & associations with drug using peers
Rawson,Gonzles, Obert,McCann, Brethen 2005
Juvenile OffendersJuvenile Offenders
44% meet clinical DSM-IV criteria for substance abuse or dependence (v.7.4%)
27.8% meet criteria for addiction (v. 3.4%)
3.6% receive substance abuse treatment
80% suffer from learning disabilities
75% have mental health disorder
“ Criminal Neglect: Substance Abuse, Juvenile Justice & the Children Left Behind” www.casacolumbia.org
Phoenix AcademiesPhoenix AcademiesModified Therapeutic
Communities
SAMSHA’s National Registry of Evidence-based Programs
Office of Juvenile Justice Delinquency Prevention Model Program Drug Strategies
Phoenix AcademiesPhoenix Academies
Residential substance abuse treatment model utilizing modified Therapeutic Community Methodology
Based on the view that substance abuse is the manifestation of underlying emotional and developmental disorder
View the community as the method of incremental social learning
On-site accredited high schools in partnership with local education jurisdiction
Adolescent Therapeutic Adolescent Therapeutic CommunityCommunity
Duration of stay (9 to 12 months) Emphasis on education, social development &
recreation Less confrontational than adult TC – focused on
growth and development needs of adolescence More supervision & evaluation by staff members Assessment of emotional, psychological &
learning disorders Use of psychotropic medications, as appropriate
Adolescent Therapeutic Adolescent Therapeutic CommunityCommunity
Expanded role of family members Behavior shaping based on introspection & self- determination & regulation Expression of appropriate age independence & autonomy supported Completion of phase objectives with two to three months of orientation; three to six months of
primary treatment; and two to three months of re-entry; twelve months of live-out (continuing care)
Activities That Promote ChangeActivities That Promote Change
Five primary, distinct, yet overlapping categories of activity:
• Behavior Management/Shaping
• Emotional / Psychological
• Intellectual and Spiritual
• Vocational / Survival Skills
• Biomedical Management
Therapeutic Community: Therapeutic Community: Behavior Shaping ElementBehavior Shaping Element
• Application of Behavior Modification Theory– Rewards for positive behavior. . .Negative
consequences. Three to One ratio. . .– Graduated rewards
• Artful application of Dissonance Theory can increase outcome of interventionsPre-decision conflict (dissonance) = post
decision commitment to the choice
A Hierarchy of Behavior Shaping A Hierarchy of Behavior Shaping ToolsTools
Incr
ease
in S
ever
ityD
ecrease in Frequency
Therapeutic Community:Therapeutic Community:Emotional/Psychological ElementEmotional/Psychological Element
• Encounter Group: Deals with the here and now. Behavior shaping
• Static Group: Consistent group of peers and leader; meets over a long period of time throughout treatment experience
• Probes and Marathons: Psychodrama etc., Special groups (ACA, Abuse) periodic and as needed.
• One-to-One Counseling: Intimacy/Shame/Guilt/Complex Emotions
• Family Counseling: Systems Treatment, Couples Counseling
Therapeutic Community: Therapeutic Community: Intellectual/EthicalIntellectual/Ethical
• Formal Learning: School, GED, emphasis on social competencies, basic skills.
• Seminars: Great thinkers, great ideas and concepts.– Philosophy – The question of life:
• Where do we come from? Why are we here?• What gives life meaning? What are our moral
responsibilities? Who are our heroes?
• Books: Available and openly referred to and discussed
• Society: Norms – Rules – Etiquette - Manners
Therapeutic Community Therapeutic Community Vocational Survival SkillsVocational Survival Skills
The Context for Lessons are the result of the Social Learning Environment
• Work is the primary way we participate in community, in society.
• Work as a teaching and learning tool. Value beyond end product.
• All tasks have meaning. They are reality based, necessary, created by need and the environmental situation: Kitchen, meal prep, housekeeping
• All Tasks include a challenge to learn something.Example: how can work teach compassion?
Therapeutic CommunityTherapeutic Community Vocational Survival Skills Vocational Survival Skills
• Move from the simple to the complex.• Emphasis on attitude as a prerequisite for
acquiring skill• Reward (hierarchical movement) is dependent
on task completion with caring and effort relevant to individual capacity – “Pride and Quality”
• Through tasks we explore and develop pro-social behaviors, values, attitudes and ethics.
Emotional CartographyEmotional Cartography
• Integration of 12 week structured exploration of emotions
• Precedes encounter group work • Preliminary measurement of resident
response to emotional competence training includes:– Decrease in emotional confusion– Decrease in impulsivity, inability to focus, etc– Increase in retention
Family & Outpatient ServicesFamily & Outpatient Services
Family Services
Mental Health Services
Outpatient Substance Abuse Services
Therapeutic Community
Pass ProposalsVisitors ListMulti-Family GroupsStipendsFunctional Family Therapy
MentoringParent CouncilSatisfaction Surveys12-Step Groups
Individual TherapyFamily Therapy
Medication Management
Random UAsPhysical Exam
Early EngagementParent EdRec DaysSFP GroupsSeeking Safety
ART Groups
Group Therapy
Tasks of the Family ProgramTasks of the Family Program
• Decrease guilt
• Increase autonomy
• Identify what didn’t work
• Learn new skills that might help
• Support each other in the struggle to grow
Elements of Family ProgramsElements of Family Programs
• Family Systems Counseling– Define family roles– Identify problem areas– Realign family members in supportive
functional relationships• Parent Education
– Current, useful information: Substance use, signs and symptoms, common drugs of abuse
– Intervention via: didactic information, practice opportunities
Elements of Family ProgramsElements of Family Programs
• Family Association:– Self-help peer support– Skills practice– Support to the program
Enhancing Resilience & the “Normal”Enhancing Resilience & the “Normal”
If we want to help vulnerable youngsters….focus on protective processes that change trajectories from risk to adaptation.
Rutter et al 2000; Werner 1993
– incremental growth & development – explore the impact of adversities– decrease negative chain reactions– increase self esteem and self efficacy– open up opportunities – expose to new ideas– connect & use existing community resources
Both with adolescents and their guardians.
Co-occurring Disorders Co-occurring Disorders Are Common In Youth Are Common In Youth
with SUDwith SUD anxiety disorders post traumatic stress disorder depressive disorders attention deficit & hyperactivity
disorders attachment disorders eating disorders sexual and physical abuse
DSM–IV DisordersDSM–IV Disorders
Attention Deficit & Disruptive Behavior
Disorders45%
Mood Disorders22%
Anxiety Disorders 33%
Co-Occurring Capability Co-Occurring Capability and Program Practicesand Program Practices
SA/MH screening and assessmentIntegrated treatment planning and serviceFull service partnerships through age 25Youth development and leadership modelsMulti-dimensional & multi-disciplinary teamRelapse prevention model of recovery Culturally sensitive
Integrated Treatment of SUD and Integrated Treatment of SUD and ComorbidityComorbidity
• Comorbidity is rule not exception
• Predictive of poorer treatment outcomes
• Most teens not treated concurrently
• Treating one disorder doesn’t treat the other
• Research and clinical consensus supports integrated treatment
Barriers to Integrated TreatmentBarriers to Integrated Treatment
• Funding agencies have not implemented integrated treatment – funding stream & licensing barriers
• Critical shortage clinicians w/ experience & training• Exclusion from efficacy trials
– little known about interactions drugs/ medications– adolescents first referred to SA treatment– treatment of psychiatric disorder contingent on
Successful SUD treatment & stable abstinence prior to pharmacotherapy for comorbidity
• Separate funding streams dis-incentive integrated & coordinated care
Early Peer-Supported Relapse Early Peer-Supported Relapse Prevention & Continuing CarePrevention & Continuing Care
– Strong Transition Phase of Treatment with increased independence and autonomy (Re-Entry Phase)
– Emphasize relapse & how to handle it not failure – Develop detailed plan for relapses and intensification of
treatment until re-stabilized– Family education and involvement – positive adult mentors– Involve in pro-social activity, incompatible with drug use
while in treatment – Establish coordinated continuing care plan for all problem
domains which is initiated during active treatment phase– Involve in positively reinforcing; incompatible drug use;
positive peers– Maintain contact and establish mechanism for early
treatment re-entry when lapses occur
Barriers to Treatment for Barriers to Treatment for Troubled YouthTroubled Youth
client
family
community
organizations
program
systems
Early EngagementEarly Engagement
– Motivational interviewing – Slower presentation of information – Involve parents/guardians early
• Focus on opportunity to correct educational deficits
– Build ties to program through big brother/sister– Early intensive case management – weekly contacts
with family members & probation from beginning– Stay in contact with family and probation officers if
drop out occurs (encourage return to treatment) – Parent orientation and education – Assessment-assessment-assessment