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

Self

Family

Adolescent Substance Abuse Adolescent Substance Abuse TreatmentTreatment

Education

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

Fragmented and conflicting mission and goals between referral, funding and oversight agencies

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

Phoenix House

Fashion Awards