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Chemical dependency among adolescents continues to present significant challenges to helping professionals. This article discusses the variety of approaches used to treat chemical dependency. An adolescent program that integrates the strengths of different perspectives and techniques is described.
Although publicity about the problem of chemical dependency has increased in recent years, there has not been enough emphasis on various approaches used to address it. Counselors, teachers, and the general public need information about treatment models and resources that are available to them. Increasingly, master's-level counselors are finding employment in substance abuse programs (Hosie, West, & Mackey, 1988). To be effective, they must understand various approaches used in chemical dependency treatment and be able to integrate them into their work. Those in the chemical dependency treatment field itself, however, must first become clearer about when and how to use various approaches. Unfortunately, chemical dependency professionals have too often engaged in bitter division about using different approaches rather than "joining forces" toward more integrated and comprehensive care (Schonfeld & Morosko, 1988).
The purpose of this article is first to provide an overview of different treatment perspectives in the addictions field. I then argue that combining various approaches in treatment is the most effective way of addressing the array of needs that chemically dependent clients present. In particular, the treatment needs of adolescent clients with addictions are emphasized.
Treatment for Adolescents
Ehrlich (1987) has described many critical differences between treating adolescents and adults. He pointed out that unlike adolescents, adults generally have a well formed identity prior to becoming dysfunctional. They can refer back to this identity in treatment and work toward regaining losses that resulted from their addiction. Adolescents, however, can refer back only to the identity of a much younger person in a very different developmental stage. Chemically dependent teens have developed an integral sense of who they are mat is centered on the use of alcohol and other drugs. Through drug intoxication, they have attempted to have fun, relieve stress, heal emotional pain, and develop peer relationships. It must be recognized in treatment, then, that chemically dependent adolescents are to a large extent being asked to give up their identities and develop new ones.
Ehrlich (1987) argued that teens in treatment must learn to change their sense of identity by finding new ways of having fun, managing emotions, and relating to their peers. The treatment model he described very strongly emphasizes the twelve-step model of recovery along with psychodynamic groups, educational groups, and wilderness experiences.
Golden and Schwartz (1988) suggested that in treating adolescents with chemical dependency, counselors need to pay attention to several specific stages of adolescent development. Adolescent development is not perceived as one phenomenon to be contrasted with adult maturity but is broken down into three distinct phases. Counselors must recognize that chemical dependency in early adolescence disrupts the development of the client's ability to tolerate emotions. Among adolescents in the middle-age phase, the critical issues shift to avoidance of conflict and a sense of false intimacy with drug-abusing peers. Older adolescents with chemical dependency tend to have difficulty with individuation and are overly dependent on family and peers. To be effective, treatment interventions must consider which of the aforementioned developmental stages applies to each client, and therapeutic efforts must address the issues that are relevant to that stage. Golden and Schwartz (1988) stressed the critical importance of programs being flexible enough to adapt to the treatment needs of different developmental stages of adolescence.
The high incidence of chemically dependent adolescents with concurrent psychiatric disorders is another factor that programs must address (Chatlos, 1989; Schiff & Cavaeola, 1988). These dual diagnosis clients have significant problems with depression as well as high rates of attention deficit, sexual abuse, and physical abuse disorders (Schiff & Cavaeola, 1988). To be effective, treatment approaches must incorporate assessment procedures that will recognize these coexisting diagnoses and develop appropriate plans to treat them.
Chatlos (1989) described a program specifically geared to the needs of adolescent dual diagnosis clients. The model described begins with a thorough neuro-psychiatric evaluation that assesses physical, psychiatric, and chemical dependency problems. If there is a medical condition that is contributing to the client's problems, provisions for appropriate treatment are made. Psychiatric medications that are needed to address specific diagnoses are prescribed at the onset of treatment. Central to the treatment approach is addressing the addiction as primary rather than viewing it merely as a reflection of underlying psychopathology. Generating a commitment to abstinence from clients becomes a critically important first goal. Clients must also commit to abstaining from other dysfunctional behaviors related to psychiatric problems (e.g., engaging in self-mutilating acts, attempting suicide, binging and purging, and destructive dieting).
The viewpoint taken by Chatlos (1989) is that only after dysfunctional behaviors cease can meaningful counseling begin. The counseling approach described emphasizes a close examination of "structures from the past" that emerge after the commitment to abstinence is achieved. These "structures" are described as patterns of behavior that can then be addressed from various theoretical viewpoints (e.g., psychodynamic, cognitive, behavioral). This approach allows for examination of individual client issues within a group-oriented, milieu environment. The program also emphasizes the use of twelve-step meetings and integrates twelve-step assignments into the treatment planning process. Clients are expected to know and apply the first 5 steps to the problems and difficulties they are dealing with in treatment on a daily basis. A major strength of the model is that it helps to foster communication between professionals of different disciplines and the development of an integration of various approaches.
Although many treatment programs similar to those described earlier are taking steps in the right direction for developing more comprehensive, integrated treatment approaches, important elements are still lacking in them. The models described by Chatlos (1989) and Ehrlich (1987) incorporate twelve-step principles into treatment along with professional counseling in a group-oriented, milieu environment. They, however, do not describe in any detail how clients' family members are involved in treatment or how family work is integrated and coordinated with other modalities. Furthermore, therapeutic community philosophy and techniques per se are not mentioned. Lacking in the earlier models are the following elements of therapeutic community treatment: (a) an emphasis on the critical importance of peer group involvement within a strongly bonded milieu community, (b) a description of a client government or chain of command to help monitor and enforce clients' compliance with their job responsibilities and program expectations, (c) the use of "confrontation" and "support" groups to help involve clients in one another's treatment, and (d) a behavior modification system that involves staff supervision of clients giving each other consequences for rule violations and reinforcements for compliance and progress in treatment.
Many programs that explicitly identify themselves as "therapeutic communities" and incorporate the aforementioned elements of therapeutic community treatment into their programs ignore other important components of chemical dependency treatment. For example, the therapeutic community model described by Yeager, DiGiuseppe, Olsen, Lewis, and Alberti (1988) does not mention the use of any twelve-step principles or AA meetings in their treatment approach. They also fail to mention how, if at all, family members are involved in treatment.
Reflection Exercise Explanation
Reflection Exercise #1