Treatment of Dually Diagnosed Adolescents: The Individual Therapeutic Alliance Within a Day Treatment Model

Approaches to Drug Abuse Counseling U.S. Department of Health and Human Services, National Institutes of Health Elizabeth Driscoll Jorgensen and Richard Salwen 1. OVERVIEW, DESCRIPTION, AND RATIONALE 1.1 General Description of Approach

This chapter describes a day treatment model for adolescent drug abusers with a comorbid psychiatric disorder, with emphasis on those aspects of the individual counselor’s relationship with the adolescent client specific to this program. Clinical techniques are described as they relate to the common treatment goals of motivating adolescent clients toward abstinence from alcohol and other drugs (AOD) and other self-destructive behaviors, preventing relapse, assisting adolescent clients in learning to recognize and tolerate strong affective states, and developing alternate coping mechanisms to drug abuse as a means of regulating these affective states. The importance of a sophisticated integration of psychodynamic clinical techniques with traditional chemical addiction or 12-step recovery model techniques is discussed as central to an effective working individual alliance with dually diagnosed adolescent clients within both group and individual treatments. Finally, a specific analysis of the interpersonal dynamics of the client-counselor relationship and the individual characteristics of the counselor is presented and discussed as central to the effectiveness of this model.

While biological and social factors play an important role in the etiology and maintenance of addictive behavior, it is the various psychological vulnerabilities that underlie the abuse of mood-altering drugs in adolescent clients that are central to the goals, structure, and function of the Center for Child and Adolescent Treatment Services (CCATS) Model. The uses of social reinforcement as a primary treatment technique, the referral of adolescent clients to 12-step meetings like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and the use of traditional, educationally oriented counseling techniques and teaching of “the disease model” of alcoholism and addiction are discussed in depth in this chapter.

It is the authors’ hypothesis that most of the adolescent clients treated within the CCATS Model have underlying deficits that have roots in the common experience of trauma, including pervasive sexual and physical abuse, loss, and inadequate parenting, in addition to the complicating factors of learning difficulties, parental alcoholism and drug abuse, and longstanding behavioral and emotional difficulties. These combined predisposing or premorbid psychological vulnerabilities can be characterized as consisting of various clusters of characterological deficits, deficits in self-structure, and patterns of maladaptive coping that have been longstanding and in fact may have been learned from earliest childhood as attempts by the child to adapt to a chaotic and unsafe emotional environment (Wood 1988). In this light, drug abuse is viewed as an effort to self-medicate (Khantzian et al. 1990).

1.1.1 Program Description. ?

CCATS is a service of the Danbury Hospital, a teaching facility located in Danbury, CT. Adolescents 12?to 18 years old and their families make up the population being served. Adolescent clients presenting for treatment come from inpatient hospitalization; referrals from schools, court, and outpatient agencies; and family referrals. The CCATS Model serves both adolescent clients with a primary psychiatric disorder and those who are dually diagnosed?those with a coexisting psychiatric disorder and drug abuse and/or addiction disorder as diagnosed using DSM-IV criteria. The program description that follows focuses on the dual-diagnosis treatment track of the program, although many components of the program structure are the same for both clinical populations. Adolescent clients attend treatment for 4 hours a day, 5 days a week initially, and then transition to a 3-day-per-week program as they prepare for discharge and aftercare. Average length of stay is 6 to 8 weeks, with variations in length of stay determined by severity of symptom profile, psychosocial stressors, and global assessment of functioning upon intake and admission and during course of treatment. The involvement of family members or a foster parent or legal guardian is mandatory, as this involvement is viewed as essential to successful treatment outcome.

Adolescent clients must be willing to accept the structural requirements of the program, which include daily urine drug screening, random testing for blood alcohol level through the use of a breathalyzer, attendance at a minimum of three 12-step meetings (AA, NA, or Cocaine Anonymous [CA]) in the community outside of program time, and agreement to the disclosure of any relapse or serious violation of program rules or self-destructive behavior to their participating family members or legal guardians. Adolescent clients are also required to be enrolled in an educational program, usually a modified day at their own junior or senior high school, that could include tutorial or graduation equivalency diploma (GED) preparation.

Given this extensive level of behavioral expectations and limits around the amount of continued drug use while in treatment, candidates for this treatment approach must have at minimum a modest amount of motivation to establish abstinence. Motivation for sobriety is first assessed at the time of the initial evaluation and then on an ongoing basis throughout the course of treatment. Motivation may come from internal or external sources, but it is viewed as deriving from the adolescent client’s distress. This distress may take the form of disappointment in self, depression, guilt, or fear of consequences (i.e., legal, familial, biological). Evidence of the nature and extent of this distress is actively solicited during the intake/assessment interview. Clinical staff make a conscious effort to maintain or heighten this distress in treatment, eventually working with the adolescent client to help shift his or her distress from being external to internal and from being punishment oriented toward being health oriented. Adolescent clients with a strong history of conduct-disordered behavior must be able to manage these behaviors in a less restrictive environment, as the CCATS Model uses only behavioral reinforcement techniques and “time out” in a nonrestricted environment for infractions of rules.

1.2 Goals and Objectives of Approach ?

Drug abuse and chemical addiction are viewed as primary disorders and are addressed as such. This clinical emphasis on the primacy of drug abuse disorders is based on the observation that adolescents actively engaged in regular use of mood-altering drugs have significant difficulty addressing any other treatment goal and in fact most often exhibit disinhibited expression of aggressive impulses and acting-out behaviors. Thus, the hierarchy of treatment goals, although individualized and specific to each adolescent, begins with the motivation of the adolescent toward abstinence from alcohol and other drugs and the decrease and ultimately the cessation of any use of mood-altering drugs. The secondary treatment goals are individualized but can be categorized as specific to the dominant psychiatric illness that is comorbid to drug abuse. For example, an adolescent client who presents with major depression disorder will have as treatment goals reduction and cessation of acute depressive symptoms. An adolescent client displaying conduct disorder with drug abuse will be encouraged to adopt treatment goals of cessation of the conduct-disordered behavior and development of alternative coping mechanisms to acting-out behaviors. In addition, the program focuses on the successful management of prominent self-destructive behaviors. Examples of typical behaviors observed in this population might be stealing, lying, school truancy, oppositional and defiant behaviors, sexual promiscuity, unnecessary physical risk taking, and social involvement with peers who are involved in drug use and antisocial behavior. The treatment philosophy emphasizes a reasoned, democratic, educational focus on the impact of self-defeating or self-destructive behaviors on the adolescent client’s own personal goals and experience of conflict within interpersonal relationships and the experience of intrapsychic distress and anxiety.

Given the strong influence of the family’s overall level of functioning, treatment goals always incorporate some measurable behavioral improvement in family functioning, from a decrease or cessation of intense conflict within the family to the referral of parents or siblings to their own treatment outside the program structure for psychiatric or drug abuse treatment, which is viewed as detrimental to the safety and psychological well-being of the adolescent client.

Finally, additional treatment goals in this approach are determined by the adolescent clients themselves. Examples of self-selected treatment goals include pursuing educational and vocational interests, exploring transferential phenomena, examining psychological conflicts, pursuing spirituality in a 12-step program or elsewhere, and exploring new or previous recreational pursuits or interests.

Lifestyle change is central to accomplishing most of the significant treatment goals within this model, most importantly the acceptance and adoption of an abstinent or “recovering” lifestyle through the positive influence of the prosocial culture of the treatment milieu and referral to meetings such as AA and NA.

1.3 Theoretical Rationale/Mechanism of Action ?

Within the Dynamic Integrated Treatment Model, the theoretical rationale is that drug abuse is an overdetermined phenomenon maintained as a behavior (despite significant negative consequences) because of its adaptive function as self-medicating underlying depression and overwhelming affective states (Bukstein et al. 1992; Fairbairn 1981; Khantzian 1978). Because of this assumption of the primary etiology of the behavior of drug abuse, all other aspects of the model are informed by the adolescent client’s specific core issues related to loss, trauma, psychiatric illness, and related underlying vulnerabilities.

Within this framework, resistance to the establishment and maintenance of abstinence is seen as normal, predictable, and key to the establishment of long-term behavioral change. The mechanism of action within this model includes the provision of ego-supportive psychotherapy, as well as dynamically informed interpretation of an adolescent client’s resistance and the underlying dynamics that block that client’s ability to accept strategic or more behaviorally oriented counseling help. Furthermore, the mechanism of action is the use of the therapeutic alliance with the treatment staff to help adolescent clients consciously acknowledge, understand, and integrate aspects of their resistance to change and growth through the establishment of abstinence. Facilitating this process are various methods of behavioral and cognitive structure that are described in detail in this chapter.

1.4 Agent of Change The adolescent client is viewed as the primary agent of change; however, the use of group affiliation with both the treatment milieu and 12-step fellowships outside of treatment serves as powerful motivation for adolescent clients, as do the individual relationships and alliances with the counselors within the program. Although these factors provide influence and structure, the emphasis is placed on the adolescent client’s decision to absorb and use the structure, treatment, advice, and reinforcing aspects of these varied parts of the treatment. Any emphasis the adolescent client may make in attributing the causative factors of change as being outside of his or her self is carefully examined and interpreted. Counselors foster an environment where the adolescent client gains self-esteem through gradual acknowledgment of self-efficacy and internal locus of control in choosing to use the social and therapeutic support systems provided through the treatment center.

The language used by treatment staff, the behavioral expectations the staff have for adolescent clients, and the means through which behavioral limits are set and consequences given for the violation of behavioral limits make clear the underlying assumption of the treatment culture. Within this model, adolescent clients are viewed as responsible for their own behavior and ultimately responsible for the behavioral changes necessary for establishing and maintaining an abstinent or “recovery” lifestyle. While initial behavior change is acknowledged as difficult and painful at times by the staff’s empathic feedback and explorations of ambivalence, the adolescent client is still viewed to be self-regulating and able to tolerate the difficulty inherent in change through use of appropriate social support and diversion techniques. The adolescent client is also encouraged to begin to recognize his or her abdication of responsibility outside of his or her self as central to the current difficulties.

1.5 Conception of Drug Abuse/Addiction, Causative Factors Central to the understanding of this treatment approach is a description of the conceptualization of drug abuse and dependence and their relationship to coexisting psychiatric disorders. Within this approach, drug use by adolescents is viewed as a social norm, whereas drug abuse and addiction are viewed as symptomatic of psychological vulnerabilities and an attempt to self-medicate affective states of sadness, anger, anxiety, frustration, and depressive symptoms. It is held within this model that depressive disorders and psychiatric symptoms predate the onset of drug abuse disorders in adolescents (Christie et al. 1988; Deykin et al. 1987; Newcombe et al. 1986).

The model of drug abuse and addiction as a biopsychosocial disease (Engel 1980) is a helpful conceptualization that incorporates all known components of etiology. This model is presented to adolescent clients within educationally focused treatment groups and appears to be both readily understood and intuitively accepted as an organizing conceptual framework for further exploration of an adolescent’s individual involvement with chemicals, patterns of use, and family and social influences on use patterns.

In summary, drug abuse and chemical addiction are viewed as manifestations of underlying psychosocial vulnerabilities that may also be strongly influenced by biological, familial, and social factors that, once behaviorally established, present a relatively homogeneous pattern of symptoms and behavior. This pattern varies with respect to individual differences, level of drug use, and duration of drug abuse but does include behavioral deterioration, character disorganization (including a disinhibited expression of anger and aggressive impulses and an increase in acting-out behaviors), increased mental preoccupation with drug use and behaviors associated with the obtaining of and opportunity to use drugs, and finally the physical, mental, spiritual, and emotional deterioration of the individual. This model views drug abuse and chemical addiction in some instances as attempts by the individual to self-medicate overwhelming affect in the absence of alternative coping mechanisms.

2. CONTRAST TO OTHER COUNSELING APPROACHES 2.1 Most Similar Counseling Approaches As previously described, the actual treatment format is varied and includes multiple modes of care. Common to the various modalities is the counselor’s use of psychodynamic interpretation of resistance and the empathic exploration of ambivalence toward abstinence and treatment. This approach is most similar to the techniques of motivational interviewing (Miller and Rollnick 1991) and the transtheoretical approach of Prochaska and DiClemente (1984). The clinical techniques common to these approaches? including eliciting ambivalence, reframing, providing advice and empathic feedback, and using a directive yet nonconfrontational approach?are employed as powerful therapeutic tools during assessment, initiation, and active treatment phases. As in the Minnesota Model, adolescent clients’ dishonest, manipulative, exploitive, or drug-using behaviors are directly confronted; however, this limit setting serves to allow the client the access to affect required for true change to occur through the disruption of the established pattern of projection of affect and acting out. Similar to traditional psychodynamic models, the counselor employs techniques of dynamic interpretation of resistance, transference, and acting-out episodes, albeit in the context of a treatment approach, which is actually quite directive and firm in setting limits with the adolescent client.

Borrowing heavily from the theoretical framework and resultant clinical techniques of the Motivational Interviewing Model, psychodynamic interpretation of resistance and acting out is added only in the context of a well-established individual relationship between client and counselor. This individual relationship of client and counselor is viewed as the central, unifying framework through which all treatment goals are formulated and implemented. The overall intellectual and clinical structure of the CCATS Model is in fact an eclectic formulation that integrates the compatible techniques of the models of stage change/transtheoretical; psychodynamic; and traditional, Minnesota Model, or 12-step recovery model techniques.

2.2 Most Dissimilar Counseling Approaches The model differs most from a confrontational, traditional chemical addiction model where a client’s resistance or ambivalence can be framed as a “lack of willingness to surrender” or as a symptom of denial or willfulness. Ambivalence within the integrated model is viewed as normal and predictable and as an important part of the process of initiating abstinence and maintaining sobriety. The use of empathic, reality-focused feedback on the part of the counselor is seen as aiding in the adolescent client’s own self-exploration and ultimately self-motivation toward behavior change. This treatment approach is also differentiated from a traditional psychodynamic model in which the counselor declines an active, directive approach and the focus is solely on underlying dynamics and psychological vulnerabilities beneath drug abuse to the exclusion of direct questioning and exploration of the impact of drug use. 3. FORMAT The combination of a variety of treatment modalities, including individual, group, and family therapy; educationally focused chemical addiction groups; use of therapeutic challenge (e.g., rock climbing, high ropes course, hiking); expressive arts psychotherapy; goal-setting groups; peer feedback groups; staff feedback groups; relaxation training; and psychopharmacology (when appropriate), create the essential treatment provided with the program. There is also an extensive use of behavior modification techniques within the structural framework of the program, including the use of a “level” status and privilege system and the extensive application of various reinforcement techniques including the celebration of adolescent clients’ sobriety “anniversaries” of 30, 60, and 90 days clean and the use of a token system with the award of stickers depicting recovery-oriented “slogans” and sayings and peer and staff positive verbal feedback when adolescent clients have consistently refrained from the use of self-defeating or destructive behaviors and successfully used alternative coping mechanisms.

The encouragement of peer leadership and the nurturing and teaching of leadership skills are also essential aspects of the treatment format. Techniques include assigning responsibility to the senior members of the treatment community for orientation to treatment structure, rules and use of 12-step support groups and teaching of appropriate alternative coping mechanisms to drug use, and other acting-out behaviors through peers’ disclosure of personal experiences with each other in group and informal settings. The counselors serve as guides for this process, but the adolescent clients themselves are delegated the responsibility for these tasks.

Comparison of the CCATS Model with other models.

Adolescent clients’ use of 12-step support groups is monitored through the creation of daily recovery goals that are behavior specific to attending meetings, associating with new “clean” peers, and acquiring an AA/NA or CA sponsor (a senior member of the recovery group who acts as a guide and provides individual support). Finally, bibliotherapy is also an important part of the structural format of the program. Adolescent clients are given books, pamphlets, and a personal recovery workbook that has worksheets and didactic materials on relapse prevention (RP), the biopsychosocial model of addiction, the self-medication hypothesis, effects of AOD on the body and mind, effective management and expression of anger, and various topics related to recovery from addiction. The completion of several of these required reading assignments and consistent attendance at 12-step meetings are included as key criteria (in addition to individualized treatment goals) to obtaining an increase in the client’s level in the status system.

? Traditional Psychodynamic Model Dynamic Integrated Treatment Model Disease Model of?Alcoholism Etiology Psychological issues underlie all addiction; drug/ETOH use viewed as a symptom Biopsychosocial model; drug abuse/addiction viewed as overdetermined phenomena Biological basis for addiction; psychological factors seen as resulting from use of AOD Treatment techniques Primarily individual focus on dynamics of personality/long-term, insight-oriented therapy Education/peer support; referral to 12-step programs; ego-supportive/dynamic psychotherapy; urine drug screens Medical treatment; education/peer support; referral to 12-step programs with reinforcement for this participation; urine drug screens Resistance Interpreted in the transference Explored, clarified, interpreted, confronted; transference to therapist/program and AA interpreted Confronted; client seen as not willing to surrender or not willing to maintain sobriety if therapy fails Treatment goals Insight into intrapsychic and interpersonal dynamics resulting in cessation/reduction of symptoms Abstinence from AOD; insight into dynamics of self and relationships; symptom relief; 12-step commitment/participation Abstinence from AOD; 12-step participation and commitment.

Description of an Addiction Counseling Approach

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