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Effective Counseling Interventions for Adolescents with Substance Abuse
Substance abuse is an unhealthy pattern that continuously causes problems nationwide as it can lead to medical, psychological, financial and legal consequences (Butler Center for Research, 2016). Substance abuse has been a growing concern during adolescent development due to an inability to recognize the consequences of using harmful substances (Much, 2001). According to Muck et al. (2001), adolescents are more likely to progress rapidly from casual use to substance dependence. Adolescents are a vulnerable population that are at a higher risk of developing a Substance Use Disorder (SUD, (American Psychiatric Association, 2013). In comparison to adults, adolescents need more intense interventions because of the complexity of their problems and where they are in the stages of the change model. Due to the likelihood of dependence and the need for a more intensive approach, it is essential to find effective interventions and to explore the role the counselor plays during this process. Interventions that have shown efficacy are Cognitive Behavioral Therapy (CBT), forms of family therapy (MST, FFT, MDFT, BSFT) and Therapeutic Communities (TC), (Muck et al., 2001).
Adolescents are less likely to seek treatment due to their inability to distinguish casual substance use from addiction. Adolescents are also more likely to be referred to some form of therapy making their lack of motivation to change aconcern since they aren’t actively seeking treatment (Muck et al., 2001). According to Pallonen (1998), adolescents who smoke cigarettes are typically in the same stage when they are contemplating quitting and before making any commitment to change. Pallonen (1998) discusses the importance in creating an intervention that targets adolescents who are in the precontemplation stage which is when adolescents show more resistance and are less likely to admit their problematic substance use. Adolescents who are in the preparation stage are the ones who will typically participate in an intervention that will lead them to recovery. One of the counselors main goals is to make a note of what stage an adolescent is in which helps them decide which intervention is more beneficial for the adolescent.
Although the type of intervention that is used with the adolescent is important, the therapeutic relationship is essential in creating positive change. Auerbach. May, Stevens and Kiesler (2008) conducted a study to see how the client and counselor relationship perceptions impact the treatment outcome. For this study, the Working Alliance Inventory (WAI) and Impact Message Inventory Circuplex IMI-C were given to both the counselor and the client during week two of treatment. The results of the treatment indicated that when the client and counselor felt both affiliation and friendliness, they believed there was a good working alliance which correlates with the outcome of treatment (Auerbach et al., 2008). Although this is just one study and Auerbach et al. (2008) mention that there are limitations, the results serve as a good basis for future research and indicates the importance of a healthy rapport.
The intervention that is most commonly used and that has shown the most effectiveness with individuals suffering from addiction is the 12-step program. The 12-step program is based on Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and is typically faith based (Taylor, 2010). This kind of intervention can be done in groups and it can also be done individually with counselors and with family members (Muck et al., 2001). Counselors who work in the substance abuse field are often recovering users themselves so they serve as a role model for the adolescents. Adolescents might be able to connect more with a counselor who has been through relatable struggles and this will lead to more effective outcomes (Auerbach et al., 2008).
The 12-step model that this intervention follows helps guide adolescents to create change step by step, which begins with deciding to change and ends with ways to maintain the change. According to Muck et al. (2001), those who complete the 12-step program are more likely to remain abstinent from using a substance 6 months after treatment. It seems that compared to those who don’t complete the program, those who do complete the program are more likely to remain abstinent after one and even two years. 12-step programs are now offered in residential and outpatient settings making it more convenient and accessible to those looking for treatment.
Another frequently used intervention by counselors is Cognitive Behavioral Therapy (CBT), which can also be referred to as cognitive therapy, or behavioral therapy (Muck et el., 2001). The purpose of CBT is to change a learned behavior by altering cognitions and by using interventions that modify addictive behavior. Counselors help adolescents unlearn the addictive behavior and aim to find positive outlets that help the adolescent cope with stressors (Muck et al., 2001). According to Dingle, Gleadhill and Baker (2008), CBT for young substance abusers involve teaching skills, trying to identify the consequences of substance use and aiming to figure out what caused the substance abuse to manifest.
CBT is all about teaching adolescents how to use coping strategies and how to change the thoughts and behaviors that are attached to addiction. The skills that are taught to the adolescent during CBT will allow them to avoid substance use when they encounter situations that are high stress for them (Dingle, Gleadhill, Baker, 2008). In CBT counselors help adolescents face their addictive behavior and come up with steps that lead to positive behavior change. According to Dingle, Gleadhill and Baker (2008), research shows that CBT is effective in treating a range of addictive behaviors. Some of these addictive behaviors include misusing alcohol, tobacco, stimulants, opiates and other drugs.
CBT is a unique intervention because it not only targets behavior but it also targets the adolescent’s thoughts (Muck et al., 2001). Unhealthy cognitions can lead to negative behavior so if cognitions are targeted and cognitive restructuring is used, it will help adolescents refrain from using the substance (Sussman,Skara, and Ames, 2008). Some of the skills that are taught during CBT include nonverbal communication, alcohol refusal, conflict resolution and problem solving skills. These skills are then practiced in either a group or an individual setting so that the adolescent can see how the skill can be used (Muck et al., 2001). It is important to use situations that the client might find themselves in during role play and practice so that they can apply it in their every day lives. CBT has shown great efficacy when it comes to treating adolescents especially those with more severe substance use.
While CBT aims to change negative cognitions and behaviors during intervention, Family Therapy looks at the substance abuse as something that is stemming from a family distortion (Sussman et al., 2008). The goal of family therapy is to determine how the family is playing a role in the adolescent substance use (Taylor, 2010). When a counselor conducts family therapy, he or she is able to directly observe some of the behaviors of the family and how family functioning is demonstrated so that they can better assist the adolescent. According to Taylor (2010), there are three parts to the family, which are “the person’s family of origin, the nuclear and the extended family”. When there are distortions in these three areas and lack of communication including limits by the parents, there is room for the adolescent to seek substances to divert pain, fear, anxiety, etc.
In general, the goals of family therapy are to engage with the adolescent and the family so that the family can help intervene in the adolescents substance use (Taylor, 2010). The role of the counselor is to coach the family members on confronting the adolescent and to teach them about the risks that the substance of choice can cause. Family therapy is similar to CBT in the sense that with family therapy the counselor is also teaching coping skills as well as parenting skills (Taylor, 2010). The difference is that the family is incorporated into the intervention and is also being taught skills that will benefit the adolescent. Four family therapy approaches that have shown efficacy with adolescent substance abuse are BSFT, FFT, MDFT and MST (Baldwin et al., 2012).
Brief Strategic Family Therapy (BFST) is a brief intervention that not only targets the substance abuse but other conduct problems that may take place at home or at school (Taylor, 2010). BSFT follows three principles that include: considering that what affects one person affects another, influences that family interactions have and that this intervention is meant to “change patterns of family interactions” (Taylor, 2010). The role of a counselor during this intervention is to change the negative interactions of the family members and to really hone in on the positive interactions, as these are the interactions that will aid the adolescent in changing and maintaining change. This intervention is essential for those that are having other problems besides the substance use as it targets behavioral problems as well.
Another form of family therapy that is useful for adolescent substance abuse is Functional Family Therapy (FFT). The purpose of FFT is to improve family functioning and family interactions so that it can help change dysfunctional behaviors (Alexander & Robbins, 2010). Much like when using CBT, the purpose of FFT is to use behavioral and cognitive interventions that match the relational functioning of the family. The role of the counselor in FFT is to change behaviors within the family so that they can have a healthier relationship. When there is an adolescent suffering with substance abuse, the goal of the counselor is to uncover what is triggering the adolescent to use and if there are any dysfunctions in the family that need to be fixed. FFT like CBT also uses skills and role-playing to get the family to change their behavior (Alexander & Robbins, 2010). FFT is also done in three phases where the counselor builds alliance and motivation then teaches skills and finally generalizes them.
Multidimensional family therapy (MDFT) is much like FFT because it too has its own phases (Liddle et al., 2001). For the first month of MDFT it is crucial for the therapist to build alliance with the family and to also engage them. During this month, anyone that is part of the family system is included in the therapy. For this intervention in particular, individual characteristics are observed from each family member along with the adolescent that is abusing a substance. During the process of MDFT the therapist pulls out themes that match to each individual so that there can be a basis for treatment (Liddle et al., 2010). The goal with the adolescent for this therapy is to explore every aspect of the adolescents life and how they interact with the other family members as well as when they are in community settings. The other phases include problem solving and finding other ways to cope that does not include using substances.
Multisystemic Therapy (MST) is a more intensive form of family therapy (National Institute of Justice, 2011). The goal of MST is to advise families on how to keep track of adolescent behaviors while still using rewards and punishments. Using rewards and punishments are effective ways to help reduce or increase a behavior that the adolescent is exhibiting. The concentration for this form of therapy is on the involvement youth has in addictive behavior and how it can be changed with behavior that is more prosocial (National Institute of Justice, 2011). Since this form of therapy is more intensive, the therapist has a smaller caseload and is also available at all times for the families. This intervention was shown to be effective in regards to decreasing substance use behaviors in adolescents (National Institute of Justice, 2011) but is typically not used until the other forms of therapy have been attempted.
Although MST is a more intense form of family therapy, Therapeutic communities (TCs) are “reserved for adolescents with the most severe substance abuse and related problems” (Muck et al., 2001). This intervention is inpatient and the adolescents can stay an average of 15 months. Some adolescents can get out in as early as 6-12 months if they exhibit good behavior and follow the program as it should be followed (Muck et al., 2001). The purpose of this program is to provide the adolescent with a safe space where they can learn skills and goals in regards to their behavior with substance abuse. This program is also highly structured where each day is planned and is filled with individual therapy, peer groups, recreation, jobs and occupational training. TC has shown to be effective with adolescents who complete the program (Muck et al., 2001).
Overall, programs such as the 12-step program, BSFT, MST, FFT, MDFT and TC have shown to be effective in adolescents that complete the program. Although there has been significant evidence that point to these programs being effective with adolescents, there are still limitations to how the programs were found to be effective and what they were compared to. According to (Muck et al., 2001) a limitation to the studies that were looked at is the level of substance use by the adolescent. If a study was conducted with adolescents who have low levels of substance abuse and it’s compared to a study where there is criterion, it makes less sense to compare the two and use them to show efficacy. According to Baldwin et al. (2012) “studies are limited in comparing the models side by side”. This makes it difficult to determine which model is most effective.
According to Baldwin et al. (2012), the most significant limitation is that some interventions have shown efficacy but we do not have enough training available for the interventions. Not having enough training, limits the amount of clinicians or counselors that can use these interventions because they can only be trained by working in a setting where multiple people are using this intervention. These trainings are also very costly and a lot of practitioners may not have the funds to receive these forms of therapy (Baldwin et al., 2012). Auerbach et al. (2008) mention that while their study showed effectiveness between how the client and the counselor perceive the relationship, the results are promising and it can serve as a basis for future research. The limitation that is mentioned the most is how the studies are compared and what is truly the most effective form of substance abuse treatment for adolescents. Although a lot of studies have been conducted, more research is needed to show evidence based approaches.
Substance abuse continues to be a growing concern for the vulnerable adolescent population so it is essential to know which treatment interventions are most effective. Counselors play such a significant role in the treatment of adolescents with substance abuse because they are the ones that teach the adolescents the necessary skills to stop addictive behaviors. The different forms of family therapy while very similar help target family functioning which might be the genesis of the adolescents substance abuse. CBT helps adolescents change their cognition and create plans to change their behaviors. 12-step programs are widely available making it easily accessible to those in need. TC is a more intensive option that is needed for those adolescents who are more severe. All of these interventions have shown to be effective and can be used by counselors to target substance abuse in adolescents making for more efficient outcomes.
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