Adolescents and Young Adults: Finding the Best Methods of Treatment
This edition of Counselor magazine has a focus on adolescents and young adults. With that in mind, what do we know about these two populations? How are they alike and how are they different from one another? How do they differ from mainstream adult patients?
Let’s begin the discussion with the concept of rehabilitation, which implies a return to an earlier level of successful functioning. Adolescents have not achieved this earlier level simply because they are not old enough to have had sufficient experience in developing successful coping strategies. Unlike adolescents, young adults with substance use disorders (SUDs) have the had the time (years of life) to develop successful coping strategies, but the early drinking and/or drug use may have deprived them from the opportunity to develop these skills. When young people, who still have developing brains, are in the midst of an active addiction, emotional growth and coping skills development are slowed or entirely arrested. Although the result for both groups is the same, they have arrived at their coping skills deficits by different routes.
If neither group has a history of successful functioning to return to, then rehabilitation is not possible and instead we must focus on “habilitation,” which involves learning the coping skills for the first time. In contrast to rehabilitation, habilitation requires more skill building and a more extensive array of tools, services, and resources to accomplish the task. In comparison, for many mainstream adults with SUDs, simply removing the alcohol and drugs that interfered with their functioning and having them recover from their disorder is sufficient for them to return to their earlier level of successful functioning.
To illustrate this difference, the demographics and clinical presentations of mainstream adult patients who presented for treatment fifty years ago was markedly different from today’s younger patients. Demographically, we had a group of patients for whom the absence of education was usually not a problem. Most had high school diplomas if not college and graduate degrees; many had job skills including technical and professional expertise; most had jobs and even careers; and if they were unemployed it was likely that they lost their jobs as a result of their substance use. If they were not living in an intact family, it was also likely an outcome of their drinking or drug use.
If they were abusing drugs, either alone or in combination with alcohol, the drugs were most likely prescription rather than illicit drugs. If they did use illicit drugs, they were referred to a “drug treatment program”—in the 60s and early 70s, with few exceptions, drug addicts and alcoholics were treated in totally separate programs. If individuals had co-occurring mental health problems, they were likely referred for psychiatric help and in fact, for some SUD treatment programs the presence of a co-occurring mental health disorder excluded them from admission. If their substance use was associated with a felony, they were more likely to end up in jail or prison—remember, these times predated the development of drug courts. Generally, those patients who were found in addiction treatment programs fifty years ago were individuals who had functioned successfully at some point prior to the onset of their SUD, and it was the disorder that led to the current dysfunction. These patients were clearly “rehabilitatable.”
Moving ahead to today’s younger patients, we find that many are not rehabilitatable, but only habilitatable. For example, there are four demographic variables that lend considerable weight to poor outcome (Zywiak, Hoffmann, & Floyd, 1999):
- Under twenty-five years of age
- Never having married or lived as married (possibly tapping attachment difficulties)
- Absence of a GED or high school diploma
With the addition of each of the four demographic variables, the likelihood of successful outcome goes down. While there may not be much we can do about numbers one and two on that list, numbers three and four are modifiable, either directly though the treatment program or by referral.
As we look at their treatment needs, it is important to recognize that older treatment models such as Twelve Step, disease model, psychosocial approaches are not irrelevant, but insufficient to single-handedly meet the needs of today’s younger patients. In order to enhance the potential for successful recovery in our younger patients, whether adolescents or young adults, we must add those skill sets that they never developed either because of current age (adolescents) or early SUDs (young adults).
In terms of treatment services, we need to consider adding trauma treatment. For so many of these patients, as well as older mainstream patients, trauma has provided the seedbed for their addiction and related problems. Many large treatment programs, realizing the extent of trauma in the history of their patients, have added a new type a clinician: the trauma specialist. While this is a very positive step, the trauma therapist’s patients tend to be those who have been easily identified as trauma survivors because of obvious recognized trauma.
When added to clinical treatment, the value of Recovery Support Services (RSS) is well known (Ciesla, 2003). RSS are not treatments, but rather they complement treatment with many of the following approaches:
- Case management services
- Finishing schooling for adolescents or acquiring a GED or high school diploma for adolescents or young adults
- College or trade school preparation
- Vocational assessment, job training, and help with employment (particularly for those patients who are ex-felons)
- Role-playing the interview situation
- Assistance with transportation, childcare, parent-effectiveness training, and money management skills
Things many successfully coping individuals take for granted such as education about how to dress for an interview and, depending on the job sought, the impediment of obvious piercings and tattoos may be appropriate. Other possible patient needs include legal services, Temporary Assistance for Needy Families (TANF), social services, food stamps, and housing assistance and services. When reviewing the four demographic variables previously listed we can and should definitely intervene with numbers three and four on the numbered list by responding to educational and vocational issues, either directly or through referral.
Pharmacotherapy, both for co-occurring mental health disorders and for addiction, should also be considered. Most antiaddiction drugs are approved for individuals as young as sixteen, although some physicians are using them off-label for even younger patients. Consideration should be given to antagonist drugs such as oral naltrexone, acamprosate, and long-acting injectable naltrexone, this latter medication going a long way toward overcoming medication compliance issues. Antagonist drugs neither create nor continue physical dependence and there is no withdrawal upon discontinuation. There are also agonist drugs that might be helpful such as methadone and the two forms of buprenorphine.
Picture a three-legged stool with the seat representing treatment outcome and each of the three legs representing one each of psychosocial treatment, RSS, and pharmacotherapy. This approach has the greatest probability of success.
If we continue to provide treatment to these adolescents and young adults as we did fifty years ago, with a discrepancy between the needs of these young patients and appropriate treatment, the result will be poor outcome. In conclusion, our task is to assist in life skills development for the first time in this population of individuals who have not had the opportunity to develop them, whether because of current age or substance use history.
Ciesla, J. R. (2003). Correlates of positive substance abuse treatment outcomes for adults completing primary treatment. Presentation at the 131st Annual Meeting of APHA, November 15–19, 2003.
Zywiak, W. H., Hoffmann, N. G., & Floyd, A. S. (1999). Enhancing alcohol treatment outcomes through aftercare and self-help groups. Medicine & Health, Rhode Island, 82(3), 87–90.