Understanding and Treating Adolescent Substance Abuse

Books

Philip P. Muisener

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  • SAGE Sourcebooks for the Human Services Series

    Series Editors: ARMAND LAUFFER and CHARLES GARVIN

    Recent Volumes in This Series

    HEALTH PROMOTION AT THE COMMUNITY LEVEL

    edited by NEIL BRACHT

    ELDER CARE: Family Training and Support

    by AMANDA SMITH BARUSCH

    SOCIAL WORK PRACTICE WITH ASIAN AMERICANS

    edited by SHARLENE MAEDA FURUTO, RENUKA BISWAS, DOUGLAS K.CHUNG, KENJI MURASE, & FARIYAL ROSS-SHERIFF

    FAMILY POLICIES AND FAMILY WELL-BEING: The Role of Political Culture

    by SHIRLEY L. ZIMMERMAN

    FAMILY THERAPY WITH THE ELDERLY

    by ELIZABETH R. NEIDHARDT & JO ANN ALLEN

    EFFECTIVELY MANAGING HUMAN SERVICE ORGANIZATIONS

    by RALPH BRODY

    SINGLE-PARENT FAMILIES

    by KRIS KISSMAN & JO ANN ALLEN

    SUBSTANCE ABUSE TREATMENT: A Family Systems Perspective

    edited by EDITH M. FREEMAN

    SOCIAL COGNITION AND INDIVIDUAL CHANGE: Current Theory and Counseling Guidelines

    by AARON M. BROWER & PAULA S. NURIUS

    UNDERSTANDING AND TREATING ADOLESCENT SUBSTANCE ABUSE

    by PHILIP P. MUISENER

    EFFECTIVE EMPLOYEE ASSISTANCE PROGRAMS: A Guide for EAP Counselors and Managers

    by GLORIA CUNNINGHAM

    COUNSELING THE ADOLESCENT SUBSTANCE ABUSER: School-Based Intervention and Prevention

    by MARLENE MIZIKER GONET

    TASK GROUPS IN THE SOCIAL SERVICES

    by MARIAN FATOUT & STEVEN R. ROSE

    NEW APPROACHES TO FAMILY PRACTICE: Confronting Economic Stress

    by NANCY R. VOSLER

    WHAT ABOUT AMERICA'S HOMELESS CHILDREN? Hide and Seek

    by PAUL G. SHANE

    SOCIAL WORK IN HEALTH CARE IN THE 21st CENTURY

    by SURJIT SINGH DHOOPER

    Copyright

    View Copyright Page

    Dedication

    This book is dedicated with hope to today's young people and their families.

    Foreword

    While there is a substantial amount of research about various aspects of adult alcohol and substance abuse problems, only recently has attention been given to comprehensive and thorough evaluation in the adolescent population. The need for research and thoughtful comment focusing on adolescent substance abuse became evident as the proliferation of drugs and alcohol use by teens reached epidemic proportions in the 1970s and 1980s. Early studies tended to take adult models and merely apply them to the adolescent population. While these studies were not without merit, the subtle and more overt differences between adults and adolescents were often overlooked. As research in this area became more sophisticated, the value of the commentary and depth of understanding increased significantly.

    The present work succeeds in integrating the varied and complex elements that impact the initiation, maintenance, and treatment of adolescent substance abuse. To achieve this, a progressive and illuminating approach, the biopsychosocial model, is used to conceptualize the problem and develop creative treatment alternatives.

    It is clear that the problem cannot be viewed as simply adult substance abuse issues in adolescents, nor will a linear line of thinking adequately address this dynamic and pervasive problem. Rather, it is the complex interaction of biological, psychological, and social variables with individual personality traits of adolescents as a distinct population that must be considered when trying to fathom the possible causes and effective treatment options for addressing this issue.

    The first section of the book sets the tone for the entire work by its focus on current issues, definitions, and perspectives on adolescent substance abuse. Adolescents are presented as a clearly defined group with unique needs and concerns, a population requiring the most sophisticated evaluation possible. Adolescent specific concerns are discussed from conceptual and treatment perspectives. The author presents the biopsychosocial premise and proceeds to consider the various interactive elements that comprise the model.

    The biopsychosocial model as it applies specifically to adolescent substance abuse is examined in greater detail in Part II. Salient issues in the biological, psychological, and social (peers and family) realm of experience for adolescents are thoroughly addressed. These vital areas are discussed in terms of the normative issues for adolescents and how impairment in these areas can cause, or be the result of, substance abuse. Understanding the interaction of adolescence as a developmental process and the impact of drugs during this time is vital to accurately assess the scope of the problem and make relevant treatment choices.

    The third section, however, is the crux of the book. The biopsychosocial model as a specific yet dynamic guide to implementing treatment is offered. Using the model as a starting point, “real life” treatment issues such as assessment, treatment planning, service provision, and the adolescent (as well as family/peer) recovery process are examined. Finally, consideration is given to adolescents who have multiple areas of impairment and subsequently require additional therapeutic understanding and skill to create the best opportunity for improvement.

    The overriding focus of the work is to guide the reader to a more accurate and useful understanding of adolescent substance abuse. By engaging the biopsychosocial model, a sophisticated integration of complex and dynamic variables is made possible. It provides a comprehensive understanding of the problem, and the greatest opportunity for treatment.

    This book takes on a formidable task. In doing so, it stimulates a provocative and progressive dialogue in an attempt to create a reality-based, integrated, conceptual model for understanding and treating this pervasive problem. It is what the field needs to move us to a more enlightened, efficient and effective position.

    Thomas M.Doolittle, Ph.D., Clinical Director, Parkview Counseling Center

    Acknowledgments

    I would like to offer special thanks to Tom Doolittle, Ph.D., for his insights and encouragement in the writing of this book. His expertise was invaluable in the shaping of the manuscript, and his good will and humor helped me in dealing with the “loneliness of the long distance writer.” I would also like to express my gratitude to a number of colleagues for their support and for their influence in the evolution of my thoughts about how to help young people. In particular, I want to thank my colleagues at Glastonbury Youth and Family Services over the past several years, and especially Carol E. Gammell, M.A., M.Ed., for consistently reminding me of the richness and integrity of working with adolescents and their families. I owe a debt of gratitude to my former colleagues at the Child and Adolescent Psychiatric Services at Mount Sinai Hospital, especially Len Kupec, C.I.S.W., for fueling my curiosity and sense of wonder about how to encourage healthy development in young people. I also want to thank Bob Sinkewicz, M.S.W., for his imaginative ideas about young people and growing up. And I owe special thanks to Cliff H. for showing me the very human face of recovery.

    In addition, I want to extend my appreciation to those people responsible for giving my book a chance. My thanks to Charles Garvin at the University of Michigan School of Social Work for his faith in this writing project at an embryonic stage, and to Marquita Flemming at Sage Publications for her enthusiasm while this writing project developed.

    I would also like to offer special recognition to Sofia Striffler and Beryl Glover for their work on the preparation and typing of my manuscript. I could not have done it without their skillful assistance.

    Finally, my heartfelt gratitude to my parents, and my sisters and their families, and to my friends for understanding about my periods of semiseclusion while I created this book. You have my love.

    Introduction

    Substance abuse has proliferated as a national health problem over the past quarter century. The reasons for this social cancer have been well documented (Musto, 1987). Suffice it to say that such a national epidemic often strikes hardest the most vulnerable segments of society. The elderly, the poor, the psychologically impaired, the culturally disenfranchised, and the young are among those populations that live in the shadows of society. This book is concerned with how the problem of substance abuse relates to one of these vulnerable groups—adolescents in society.

    Much as the problem of adolescent substance abuse has grown over the latter part of the 20th century, so also have the ways of understanding and treating this problem grown. Throughout the 1980s the trend was toward the expansion of treatment programs for adolescent substance abusers (Nakken, 1989). New understanding about the treatment of adolescent substance abuse, including the importance of family treatment, evolved and became incorporated into these expanding programs. Further contributing to these newer understandings and treatment approaches was the cross-fertilization of perspectives created by those involved with treating adolescent substance abusers. The walls were lowered among the different mental health disciplines and between the mental health disciplines and advocates of 12-step recovery. Bridges of collaboration began being built around how to best understand and treat adolescent substance abusers. It has been imperative that this spirit of cooperation among professionals treating adolescent substance abusers continue into the 1990s. Due to the changing nature of health care reimbursement, treatment providers and programs have had to reorganize around how to treat drug-involved teenagers. Creativity has been the underpinning of evolving approaches to treatment and will need to be in the future.

    As we move toward a new century, innovation will continue to be the driving force behind emerging models for dealing with teenage drug problems. Practitioners dealing with adolescent substance abuse will need to continue to cull together sometimes diverse and complex concepts and translate these concepts into practical treatment applications. Treatment approaches will need to continue being functionally eclectic with focused, yet flexible, treatment interventions.

    This book presents a biopsychosocial model for understanding and treating adolescent substance abuse. This paradigm is offered as one way of addressing the treatment community's need for comprehensive and useful models during these times of increasingly austere health care resources.

    The search for new and more helpful understandings about health and illness is a constant quest for the scientific community. Implicit in this quest is the recognition that such understandings come from the merging of ideas, often between disciplines. As Schwartz (1982) asserts,

    It is within this broad scientific context that biopsychosocial approaches to health and illness have been formulated. Stimulated by the realization that the boundaries separating disciplines were becoming less rigid, that new connections were becoming possible between disparate disciplines, and that complex problems of health and illness were turning out to be inherently multidimensional in nature, researchers and clinicians from diverse disciplines have become motivated to seek better ways of building bridges between disciplines and establishing a common set of terms and principles. (p. 1041)

    Biopsychosocial approaches are neither orthogonal nor integrative in scope. These approaches embrace the major paradigm shifts of disciplines toward multiple factorial and interacting systems. Addressing a health problem from a viewpoint of multiple and interacting understandings develops an appreciation for the many and complex factors that can contribute to an illness. At the same time, treatment of a health problem that incorporates multiple and interactive approaches respects varied and sometimes complicated treatment strategies being used as well as the different systems that need to be involved in treatment. A biopsychosocial approach to a disorder is not “the perspective” but rather “a perspective” that allows for a range of ideas and efforts to be considered.

    An addiction is a multifaceted disorder with a diverse course of manifestation. Consequently, there is a value to adopting a paradigm that addresses this multifaceted nature and diversity. A biopsychosocial model is such a paradigm. According to Donovan (1988), “The biopsychosocial model represents an emergent paradigm within the field of addictions” (p. 13). Zucker and Lisansky Gomberg (1986) have developed a biopsychosocial model applicable to the prototype of chemical addictions—adult alcoholism. Lawson (1992) has suggested a biopsychosocial paradigm of adolescent substance abusers, and Chatlos (1989) has provided a biopsychosocial model for dealing with adolescent substance abusers concurrently afflicted with a psychological disorder.

    The biopsychosocial model of adolescent substance abuse presented in this book approaches adolescent substance abusers as a heterogeneous group. Teenagers with drug problems vary in gender, psychological make-up, family background, peer affiliation, ethnicity, and socioeconomic status among other factors. Due to this heterogeneity there is a need for diversity in ways of understanding adolescent substance abuse, and a need for translating these diverse understandings into relevant treatment approaches.

    Part I of this book identifies some dilemmas encountered by treatment professionals who work with adolescent substance abusers. Chapter 1 looks at some current issues being dealt with in defining and understanding adolescent substance abuse. Chapter 2 covers some contemporary issues in treating adolescent substance abusers. These chapters suggest how a biopsychosocial model of adolescent substance abuse can help to address these issues of defining, understanding, and treating teenage drug problems.

    Part II encompasses the biopsychosocial model for understanding adolescent substance abuse that is presented in this book. Chapter 3 introduces this model and provides an overview of biological, psychological, family, peer, community, and societal components in this paradigm. Chapter 4 focuses on one of the three primary factors—adolescent psychological development—in this biopsychosocial model. Chapter 5 discusses the remaining two factors—family functioning and peer relationships—in the triad of primary factors from this model.

    Part III is concerned with the biopsychosocial model for treating adolescent substance abuse that is offered in this book. Chapter 6provides an overview of this biopsychosocial model of treatment looking at different systems—biological, adolescent psychological development, family, peer relationships, community, and society—involved in treatment, as well as therapeutic systems used in treatment. Chapter 7 details assessment issues, and dovetails with the treatment planning considerations discussed in Chapter 8. One of the three primary recovering systems in this biopsychosocial treatment model—the adolescent's psychological recovery—is the subject of Chapter 9. In Chapter 10 the remaining two primary recovering systems—the recovering family and the adolescent's peer relationships in recovery—are the focus. Finally, Chapter 11 explores how substance abuse treatment can be provided to three different high risk populations of adolescents—those with concurrent psychological disorders, those who are victims of physical or sexual abuse, or those who grew up with substance-abusing parents.

    This book has been developed and written with the needs of helping professionals and students from different orientations in mind. It is intended for mental health professionals grounded in psychological theory and a systems approach who are searching for a model that helps to integrate their knowledge with current understandings about addiction and recovery with adolescents. It is also designed for substance abuse treatment professionals familiar with traditional substance abuse treatment approaches and 12-step recovery programs who are seeking a clinically useful model for working with teenage substance abusers. In addition, this book is intended for students who are preparing to work with adolescent substance abusers and are interested in a model that promotes an inclusiveness of theoretical ideas and a diversity of treatment approaches. The overriding hope is that the breadth and depth of the model presented in this book will prove useful to any helping professional or student involved in the very challenging work of treating young people with drug problems.

    One premise accepted throughout this book is the concept of the unity of addictive disorders (Doweiko, 1990). The implication of this concept for substance use disorders is that the emphasis is on the addiction process itself, not on the substance of choice. Except where distinctions are noted, an adolescent's abuse of alcohol, marijuana, cocaine, or any other psychoactive substance is not differentiated in this book. The focus is on the adolescent's process of addiction to psychoactive substances in general.

    It is further assumed in this book that the terms substance abuse, drug addiction, and chemical dependency all mean the same thing. They are terms that represent the addiction process. Throughout this book these terms are used interchangeably for the sake of variety in language.

  • Epilogue

    Awareness about addiction and recovery has been growing steadily among helping professionals over the past two decades. The treatment of adolescent substance abusers has been correspondingly emerging as a whole new area of clinical specialty.

    The biopsychosocial model is one useful paradigm that can be utilized for understanding and treating addictive disorders. The biopsychosocial model presented in this book is adapted to the specific circumstances pertaining to adolescent substance abusers. This book's model draws from the theoretical diversity of psychodynamic theory, developmental theory, systems theory, and addiction theory, as well as from the therapeutic richness of psychodynamic approaches, cognitive-behavioral approaches, family systems approaches, and 12-step self-help approaches. In essence, this model is a recapitulation of, amplification of, and interweaving of preexisting ideas. Not all theoretical frameworks nor all therapeutic paradigms are included here. In this sense the model offered in this book is only a beginning, and far from the final word on understanding and treating teenagers with drug problems. As new ideas continue to emerge in the mental health and addictions fields, new perspectives will shape the view of and the work with these young people. This book admittedly offers a therapeutic ideal for treating adolescent substance abusers. The reality is that health care reimbursement and public funding pose constraints on the treatment decisions made by clinicians. Nevertheless it is hoped that this ideal will be equitably weighed with other considerations when treatment professionals seek to help drug-involved adolescents and their families.

    Appendix

    The Twelve Steps
    • We admitted we were powerless over ______, and that our lives had become unmanageable.
    • Came to believe that a power greater than ourselves could restore us to sanity.
    • Made a decision to turn our will and our lives over to the care of God, as we understood God.
    • Made a searching and fearless moral inventory of ourselves.
    • Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
    • Were entirely ready to have God remove all these defects of character.
    • Humbly asked God to remove our shortcomings.
    • Made a list of all persons we had harmed, and became willing to make amends to them all.
    • Made direct amends to such people wherever possible, except when to do so would injure them or others.
    • Continued to take personal inventory and when we were wrong promptly admitted it.
    • Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of God's will for us and the power to carry that out.
    • Having had a spiritual awakening as the result of these steps, we tried to carry this message to ______, and to practice these principles in all our affairs.

    The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. Permission to reprint and adapt the Twelve Steps does not mean that AA has reviewed or approved the contents of this publication nor that AA agrees with the views expressed herein. AA is a program of recovery from alcoholism—use of the Twelve Steps in connection with programs and activities that are patterned after AA, but which address other problems, does not imply otherwise.

    The Twelve Steps of Alcoholics Anonymous
    • We admitted we were powerless over alcohol—that our lives had become unmanageable.
    • Came to believe that a Power greater than ourselves could restore us to sanity.
    • Made a decision to turn our will and our lives over to the care of God as we understood Him.
    • Made a searching and fearless moral inventory of ourselves.
    • Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
    • Were entirely ready to have God remove all these defects of character.
    • Humbly asked Him to remove our shortcomings.
    • Made a list of all persons we had harmed, and became willing to make amends to them all.
    • Made direct amends to such people wherever possible, except when to do so would injure them or others.
    • Continued to take personal inventory and when we were wrong promptly admitted it.
    • Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
    • Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

    The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. Permission to reprint and adapt the Twelve Steps does not mean that AA has reviewed or approved the contents of this publication nor that AA agrees with the views expressed herein. AA is a program of recovery from alcoholism—use of the Twelve Steps in connection with programs and activities that are patterned after AA, but which address other problems, does not imply otherwise.

    The Twelve Steps of Narcotics Anonymous
    • We admitted that we were powerless over our addiction, that our lives had become unmanageable.
    • We came to believe that a Power greater than ourselves could restore us to sanity.
    • We made a decision to turn our will and our lives over to the care of God as we understood Him.
    • We made a searching and fearless moral inventory of ourselves.
    • We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
    • We were entirely ready to have God remove all these defects of character.
    • We humbly asked Him to remove our shortcomings.
    • We made a list of all persons we had harmed, and became willing to make amends to them all.
    • We made direct amends to such people wherever possible, except when to do so would injure them or others.
    • We continued to take personal inventory and when we were wrong promptly admitted it.
    • We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
    • Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs.

    Twelve Steps of Narcotics Anonymous reprinted by permission of World Service Office, Inc., Narcotics Anonymous. Twelve Steps adapted by permission of Alcoholics Anonymous World Services, Inc.

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    Author Index

    About the Author

    PHILIP P. MUISENER is a clinical social worker with the Glastonbury Youth and Family Services, Glastonbury, Connecticut. He specializes in the treatment of substance abusing adolescents and has been working with adolescents and their families for more than 12 years. Mr. Muisener holds an M.S.W. from the University of Connecticut School of Social Work, an M.S. in Counseling from Central Connecticut State University, and has been a Certified Alcohol and Drug Counselor for 8 years. He has practiced as a therapist in a variety of treatment settings. In addition, he has provided consultation and training in assessing and treating adolescent substance abuse to school systems, hospitals, and child guidance clinics.


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