The struggle to help adolescents heal from drug and alcohol addiction is not new. While at times it can be an up-hill battle, there are evidence-based treatments that are directed toward the specific needs of this population. In addressing these needs, one must understand the various elements that adolescents face.
There are many developmental consequences of substance use in teens. Research shows that the adolescent brain is very different than the brain of an adult in that it is not fully developed until twenty-five years of age (CSAM, 2009). Without a fully developed brain, the ability to understand consequences is much more difficult—assessing situations, decision making, and controlling emotions are all inhibited in adolescents because of an underdeveloped prefrontal cortex (NIDA, 2014). In addition, adolescents are generally less likely than adults to feel that they need help or to seek treatment on their own. Given their shorter histories of using and abusing drugs, adolescents oftentimes experience relatively few adverse consequences from their drug use and their incentive to change or engage in treatment often corresponds to the number of such consequences experienced (Breda & Heflinger, 2004). When adolescents do get treatment, it is often for different reasons than adults. By far, the largest segments of adolescents who receive treatment are referred by the juvenile justice system. Given that adolescents with substance use problems often feel they do not need help, engaging them in treatment often requires parents to make a decision to admit them to treatment without their consent.
Adolescents in treatment also report abusing different substances than that of adults. For example, many more people aged twelve to seventeen received treatment for marijuana use than for alcohol use in 2011 (65.5 percent versus 42.9 percent), whereas this was the reverse for adults (SAMHSA, 2013). Adolescents are also less likely than adults to report withdrawal symptoms when not using a drug, being unable to stop using a drug or continued use of the drug in spite of physical or mental health problems. However, they are more likely than adults to report hiding their substance use, getting complaints from others about their substance use, and continuing to use in spite of fights or legal trouble.
The National Center on Addiction and Substance Abuse at Columbia University (CASA) reports, “Substance use is a major contributor to the three leading causes of death among adolescents—accidents, homicides, and suicides—and substance use increases the risk of numerous potentially fatal health conditions, including cancer, heart disease, and respiratory illnesses” (2011).
Evidence-Based Residential Treatment
Residential treatment for substance abuse is effective, especially when there are specific elements involved in providing care. These elements include daily structured activities such as group therapy, individual therapy, community meetings, and didactic and physical activity (SAAS, 2013).
As a therapist in a residential treatment program for adolescents with substance use disorder and co-occurring mental health issues, my focus is on cognitive behavioral therapy (CBT) and motivational interviewing (MI), as these evidence-based interventions have been shown to be effective in treating this population in this setting (SAMHSA, 1999).
MI is a psychotherapeutic intervention that consists of three main ideas: collaboration, evocation, and autonomy. When clients are unsure that they want to stop using drugs or alcohol, MI is designed to help them through the change process. It is client-centered, yet directive in theory (Miller & Rollnick, 2002).
Many of the clients I see in adolescent programs do not want to be in treatment, and treatment will not work with external motivation alone. Tapping into clients’ internal motivation is essential for successful long-term recovery (SAMHSA, 1999). True change comes from clients’ willingness and desire to get sober (Miller & Rollnick, 2002).
Implementation of Experiential Therapy
As an experiential therapist I have the ability to utilize alternative forms of therapeutic structure that frequently may not exist in traditional therapy settings. According to Erik Erikson (1950), many of those who begin abusing substances while in adolescence are most impacted by self-identity and issues of intimacy. These issues may be represented in an inability to cope with everyday stressors, a higher frequency of relapse and deficits in both psychological and social maturity. To help assist psychological development and promotion of social growth, treatment programs should allow for variances in the treatment environment allowing for new experiences. Experiential education not only allows for building self-esteem, but building upon leadership, responsibility, and being of service to others. Additionally, rapport is built as part of an organic process that is not rushed, but rather cultivated. Such engagement is frequently enhanced and influenced by the group process.
Experiential sessions can last five to six hours, as opposed to the traditional fifty-minute hour that most therapists are limited to. I use the wilderness of nearby state and federal parks, the boxing gym, the Pacific coast, and whatever environment I think will be useful to enhance the therapeutic process, while simultaneously incorporating CBT, MI, and client-centered approaches to the work. Part of experiential therapy is adventure therapy, which involves any adventure experience that is conducted by clinicians to help change behavior (Glass, Gillis, & Russell, 2012). An example of the adventures utilized for these experiential therapies include ropes courses, swimming, hiking, rock climbing, and mountain biking.
Prior to embarking upon an adventure therapy outing, I always start with a fifteen-minute check-in. This gives me an opportunity to give participants a chance to disclose how they are doing. Typically some participants share with greater detail, but this is not necessarily required. The safety in this setting allows participants to choose what they would like to share and allows them to feel a sense of belonging, while not being forced into unnecessary or uncomfortable disclosure. The level of participation allows for me to have a sense of who in the group may be resistant and who might be open to the activity. This information also allows me to tailor which particular interventions I think will be successful or useful, which participants need additional assistance, and which participants have the propensity to support their peers.
Tae Kwon Do
Loosely translated, Tae Kwon Do refers to the “way of the hand and foot.” It is mastery through hard work. In becoming sober, recovery also becomes an art to be mastered. Meetings, sponsorship, commitments, and a spiritual pursuit are all to be practiced. There are several parallels between Twelve Step recovery and Tae Kwon Do. Instead of a belt, you become a sponsor. Rather than trophies to mark your progression and success, you are awarded chips. This parallel was an inspiration for me in my early recovery and for utilizing Tae Kwon Do as a therapeutic modality as a therapist.
The purpose of Tae Kwon Do is to be able to be accountable to other people by eventually becoming a black belt. Being a black belt means that you are no longer simply responsible for yourself, but to everyone that you teach. To be a good teacher, you must be a good student. Just as in the fellowship of Alcoholics Anonymous (AA), to be a good sponsor you have to be a good sponsee. Building confidence is also at the core of Tae Kwon Do. And, just like with martial arts, it is paramount in early recovery to have a solid foundation in which to build off of.
Billy was a sixteen-year-old high school student who was admitted to treatment for marijuana dependence. He had been smoking marijuana for over three years, had progressed to using marijuana concentrates daily, and had insisted he would not quit. The event that led to his admission was his increasing irritability and hostility towards his parents. Billy frequently stole from them, lied about his use, and threatened them with physical violence. Additionally, he had been arrested the year prior for being under the influence on his high school campus.
At school Billy was gradually becoming more and more isolated from his peers as his cannabis use increased. His grades were in continuous decline and he verbalized little to no motivation to study or participate in school activities. He made demands of his parents to purchase him expensive items, including a car, phone, and other material items, many of which were sold to buy drugs. When Billy’s demands were eventually denied, he would threaten his parents and hold their personal belongings hostage in retaliation.
When I first met Billy, I experienced a resistance atypical for most new clients. He gave no eye contact and avoided any direct communication. Knowing that Billy and some of the other residents were new and resistant, I scheduled a trip to the local water park in order to facilitate rapport building between myself, Billy, and the rest of the group.
Using Adventure to Engage Treatment Resistant Clients
During the group check-in each of the clients was encouraged to share their personal experiences, but no one wanted to talk. Rather than force the process, I honored the silence. I knew there would be ample time to let the process happen organically over the next several hours we would spend together in this experiential activity. When we arrived at our destination, the clients rushed to the hot tub. I joined the group in the large tub and observed their interactions with one another, as well as their willingness to engage with me. I was careful to not rush the process and let it happen in real time. After a relatively short period of time, I noticed the general tension in the group dissipate. The boys started to laugh and the group became more cohesive. I also noticed the boys were asking me a lot about the recovery process. In a group that is usually ambivalent and resistant toward recovery, this was a considerable step in developing a therapeutic alliance and early treatment success.
After twenty minutes the group migrated to the general swimming area. Some of the boys raced while others just floated and talked to each other. After a couple of hours, Billy approached me and was increasingly inquiring about the program. He told me about his relationship with his parents and through this dialogue I learned that he enjoyed boxing. After learning that I was a boxing coach, we discovered similarities and the beginning of what would blossom into a trusted bond. It seemed that his earlier reticence to connect had diminished. From this newly formed connection, he was able to ask questions about Twelve Step recovery, how it might apply to him, and how this new environment was one that emphasized trust and empowerment, not confrontation and shaming.
Through this gradual and organic development of rapport, I was able to utilize the adventure therapy experience to connect with Billy on a more meaningful level. Through skill building, experientially gained self-esteem, and an openness to work alongside peers towards a common goal, I witnessed firsthand the dissipation of defense mechanisms that once emotionally paralyzed Billy, and the emergence of a sense of belonging and lightness both mentally and physically.
Tae Kwon Do as Experiential Therapy
Prior to beginning each Tae Kwon Do class we do a check-in. During this part of the group I see what anxieties and problems exist in an effort to effectively utilize CBT interventions. For adolescents in treatment, putting the needs of others in front of your own can be difficult at best. However, this is essential to be successful in an experiential activity. As the dynamics of the group emerge, this can provide insight into the community as a whole, while simultaneously revealing opportunities for personal growth and change. Billy reported that he was jealous of the relationship that the other boys had with their parents and he often verbalized anger directed at his parents. I used this disclosure as an opportunity to start to work with Billy’s unresolved anger. I utilized an anger rating scale: one being not mad and ten being rage. He acknowledged that he was at a seven and I asked him to remember that number.
Upon commencing the class, the group participated in a ten-minute meditation and quick check-in. After this I led the group through all the basic fundamentals of boxing and Tae Kwon Do. For forty-five minutes I took the boys through a grueling workout followed by a closing meditation for ten minutes and group check-out. The check-out process is an opportunity for the boys to make correlations between their thoughts, feelings, and actions.
Billy was fully engaged in the Tae Kwon Do exercise and participated with enthusiasm. Halfway through the class I asked him what level his anger was at. He looked at me, smiled, and said that it was at a two. I could tell that he was starting to understand that his anger was a feeling that not only passed after certain interventions, but one that he could control. Billy continued with the exercise for thirty minutes and ended with a meditation. When the group checked out, he reported that his anger had gone from seven, to two, to zero. I asked the group how these tools could be used in the real world. They came up with a number of concrete plans on how these interventions could be used. This intervention allowed the group to discover that the meditation, and/or martial arts, could be used as a means to change difficult feelings where use of drugs or alcohol would have often been their solution in the past.
Billy’s Second Adventure
The second adventure the group participated in was a mountain biking trip of the coast of Marin, California. Before we left, we had a group check-in. Billy shared more with the group about his relationship with his parents. He also talked about how being in athletic situations seemed to help him feel better, but that he really didn’t know why. We discussed as a group why this might be and Billy was open to the ideas of the group and also contributed his own thoughts on the matter. While on the adventure therapy outing, I was mindful of modeling traits that I wanted to bring out in all the group members. I was honest, kind, and willing to meet the clients where they were on that particular day. At one point I stopped to help one of the boys who fell off his bike. After modeling kindness and empathy, I also noticed every member (including Billy) being helpful toward one another. Through this adversity—and the ability of the group to realize that a team is only as fast as its slowest member—stronger bonds were built not only between therapist and clients, but also between peers. In this experiential support, an emotional closeness develops allowing for an opening to work through emotions and conflict together.
Billy’s Second Tae Kwon Do Group
On Billy’s final Tae Kwon Do group, I was able to observe his transformation into a positive group leader. Through our work together, I focused on helping Billy be accountable for his actions. One of his primary issues prior to engaging in treatment was that he would take the victim position when confronted with consequences for his own problematic behavior. In this, he could avoid accountability. When he was put in the position of a leader, he was forced to be accountable to the other clients. He was responsive to this as an intervention and was ultimately able to change his behavior, along with his mindset.
When Billy discharged from treatment, he demonstrated significant growth and was taking the idea of recovery and Twelve Step participation seriously. Billy was more accepting of his parents’ own issues and had learned how to talk to his parents, instead of acting only with hostility. He demonstrated accountability, apologizing for his actions when appropriate, and through his own sense of accomplishment and increased self-esteem Billy demonstrated increased resiliency and an ability to cope with stressors that would have consumed him in the past.
Despite the obstacles of treating adolescents for substance abuse, there are clearly evidence-based models that are effective. It is important to recognize that adolescent clients require a different approach than adult clients due to their developing brains and a developmental need to differentiate from authority figures. Alternative forms of therapy can be fun, honest, and effective. Experiential and/or adventure therapy is an effective treatment modality that serves to engage clients clinically while keeping them motivated toward change. The traditions of AA inform us that social networks play a significant role in long-term recovery and successful outcomes in substance use disorder treatment. This is especially true with adolescents.
Experiential therapy in an adolescent residential setting allows clients the opportunity to openly engage in therapeutic modalities while in a new environment that oftentimes mirrors a family-like setting. For therapy to be successful in group-centric experiential outings, it is critical that there are defined goals and roles of group members and that groups needs are seen as essential. For adolescents, this can oftentimes be key to successfully navigating discharge and a return to their family of origin. Experiential therapy not only builds upon the therapist/client relationship with increased trust and shared experiences in the field, but also allows therapists a more accessible approach to explore the problematic behaviors of clients with real time, solution-based approaches in overcoming those obstacles.
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