Treatment and Rehabilitation for Youth with Substance Use Problems

12. Treatment Approaches and Methods

12.1 Treatment Approaches and Methods: Key Expert Perspectives

Key experts were asked to identify effective treatment approaches and methods which address the major issues of youth with substance use problems. Approaches and methods were explored in relation to the following areas of need:

• health problems of youth in treatment (e.g. eating disorders);
  
• personal issues such as mental health, self-esteem and needs arising from developmental changes;
  
• interpersonal issues of importance to youth (family and peer relationships);
  
• relapse management/prevention.

12.1.1 Treatment Approaches to Address Physical Health Issues

Substance abuse impacts directly and indirectly on the health of users, although the substance abuse literature primarily addresses long-term effects on adults. Health impacts vary according to the substances used, dose, frequency and duration of use, manner of (substance) administration or results of use.

Health-related problems associated with alcohol/drug use in youth and adults (summarized by Spooner et al., 1996) include:

• reactions to drug chemistry;
  
• acute toxic effects;
  
• withdrawal symptoms;
  
• HIV infection;
  
• other blood borne viral infections (hepatitis);
  
• infections at the needle site;
  
• suicide attempts and completion;
  
• injuries (road accidents);

• mental health disorders (e.g. depression)
  
• nutritional problems and deficits;
  
• eating disorders.

An Australian study (English and D'Arcy cited in Spooner et al., 1996) found that 18.3% of all deaths in Australia (1992) among youth (15 - 19 ) were substance abuse related. Alcohol abuse was related to both road accidents and suicide. People who are heavily involved in substance abuse during adolescence have five times the mortality rate during early adulthood in comparison with those who are not. However, many of the additional health effects of substance abuse occur after years of regular use.

Key experts identified the following approaches to addressing youth health issues while in treatment. These include:

• A comprehensive physical health assessment (involving a range of health care providers) at treatment entry;
  

We use a broad screening tool that identifies eating disorders and (other) mental health issues.

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There's a medical assessment prior to starting treatment -many of them are on medication - they are taken to appointments (i.e. nutritionist, physician, allergist, psychologist).

• A holistic interpretation of health and health assessment (including physical, psychological and nutritional components);
  
• A specific educational program component that provides comprehensive nutritional information;
  
• Easy accessibility to a range of specialists by clients and staff (e.g. eating disorder specialists, nutritionists);
  
• A cognitive-behavioural approach to treatment which helps youth explore, identify and practice elements of a healthy lifestyle. Programs need to make available a wide variety of information so that youth can access and use what they need;

Health issues usually have been approached by an educational/behavioural approaches, that makes sense for a healthy lifestyle. For example, protected sex, maintain health, eat, sleep and exercise.

• The availability of one-to-one counselling to explore health issues in depth;
  
• Staff who model healthy lifestyle choices;
  
• A proactive approach to health resources. Some respondents stressed that they like to accompany youth on visits to doctors or clinics in order to provide liaison and support.

12.1.2 Treatment Approaches and Methods to Address Personal Issues (including mental health disorders)

There is a strong association between substance use and mental health disorders. Key experts were asked to identify treatment approaches and methods which effectively address issues related to mental health. In most cases, recommendations for best practices were directed toward youth with less serious disorders (lack of confidence, poor self-esteem).

Although there was a range of responses to this question, there was consensus on only one approach - that the optimal method of addressing personal issues is a skill-building approach which supports the development of positive identity and enhanced self-esteem. Key experts defined skill building as being:

• Comprised of a number of elements, including:
  • building of self-esteem;
  • exploring the meaning of and building a healthy lifestyle;
  • learning tools for anger and stress management;
  • assertiveness skills.
    
• Taught in a variety of venues and settings using mini-workshops, creative exercises, art therapy, psycho-drama, individual counselling, group work and family therapy;
  
• Culturally appropriate (in the case of Aboriginal communities comprising teachings about traditional skills and practices and incorporating traditional ceremonies);
  
• Practical and solution-focussed;
  
• Fun, creative, experiential (including arts, crafts, games and other recreational opportunities).

12.1.3 Approaches and Methods to Address Interpersonal Issues

There appears to be a strong association between substance use problems and problematic family relationships.

In a study of 1,483 youth (ages 12-19) who had attended treatment programs in the United States, 73% said that they used substances to handle or escape family problems, 54% to "belong with friends" (Bergmann, 1995:455). A significant proportion of these youth came from families described as dysfunctional; 24% reported physical abuse and 38% parental (father) substance abuse.

Key experts stressed the importance of incorporating families in treatment through a variety of means, including family support, family therapy and parent education. The recommended structures for involving families varied. They included:

• 8-week (weekly) parent education groups;
  
• weekly support groups;
  
• intensive seminars or workshops;
  
• direct family counselling;
  
• involvement in family healing circles.

The importance of involving elders and the family was stressed for Aboriginal youth. A smaller group of respondents identified the importance of using peer groups and interactions to support exploration of interpersonal issues (See Section 15.2).

We promote learning from peers and use peer groups for modelling and practicing skills.

12.2 Best Practices to Address Relapse Management and Prevention

Relapse prevention and management is seen by key experts as an integral part of treatment. Six elements of best practices supporting relapse management or prevention were identified:

• A philosophical approach which perceives relapse not as a failure but as likely to occur and an opportunity for client growth and change;

Downplay relapse - don't make it look like a loss, it is part of cleaning up. Abstinence may not be the only route they're going. If they want to go completely clean, go through what happened when they can learn from it.

The development (with the client) of a treatment plan and a set of personal goals, small, short-term achievable goals which are visible to the client and which support feelings of success;

• A focus on identifying triggers to substance use and on teaching specific and concrete skills to handle use at critical times (i.e. what are high-risk situations, triggers, avoidance strategies, environmental supports and plans to handle risk situations);
  
• The exploration of other issues related to relapse (e.g. handling of stress);
  
• The development of a system of post-treatment aftercare and program contact. Contact may be required for up to one year or longer in some cases;
  
• The development of connections for youth in the community (counselling support, recreational and other resources) which can serve as supports and skill-building opportunities after treatment has ended.

Table 9: Specific Treatment Approaches and Methods to Support Effective Treatment: Key Expert Perspectives

Areas of Best Practice	Key Expert Themes
Physical health issues	Comprehensive health assessment at treatment entry Health assessment to include physical, psychological and nutritional status Nutritional education provided by program Easy access to specialists (e.g. eating disorders) Cognitive-behavioural approach to help define health and lifestyle goals One-to-one counselling to explore health issues Staff model healthy lifestyles Staff assist client to access health resources
Personal (mental) health, self-esteem, developmental issues	Skill-building approach which: Is eclectic Teaches healthy lifestyles, anger management, stress reduction Is practical and solution-focussed Is fun and creative Is culturally appropriate and presented with variety of venues (group/individual counselling)
Interpersonal issues	Proactive approach to involving families in treatment in a variety of ways Support for peer group interaction (learning, modelling, support)
Relapse prevention	Philosophical acceptance of relapse Short-term achievable goals are determined with youth Treatment explores triggers to relapse and responses Treatment explores other issues related to relapse (e.g., stress) and ways to address them Program provides long-term aftercare Development of connections for youth in community to act as ongoing support

12.3 Treatment Approaches: Literature Review

A focussed review of the treatment literature broadly supports the opinions of key experts, although there is an acknowledgment that "research into treatment methods needs to be increased considerably before the efficiency of one procedure over another can be identified and given recognition" (Spooner et al., 1996:6 - 14).

Catalano et al. (1990 - 1991) noted that youth post-treatment relapse rates are high (35% to 85%) and the process of relapse is variable.

Lapses may be infrequent single uses or infrequent episodes of heavy use for several days. Neither invariably lead to uncontrolled, compulsive use. Some suggest that these lapses may even constitute positive learning experiences (Brownell et al., and Marlatt and Gorden cited in Catalano et al., 1991:1105).

Catalano et al. (1990 - 1991) review of treatment outcome research associated the following elements with treatment success:

• the availability of special services which support the development of client skills (education, training, relaxation, sexual education and recreation);
  
• the availability of active recreational activities and skill-based recreational opportunities;
  
• participation of parents or a parental figure in treatment (if parents can contribute constructively);
  
• availability of family therapy, behavioural family therapy and combined structural/behavioural approaches.

Bergmann et al.'s (1995) post-treatment study of 1,483 youth in more than 30 in-patient and residential treatment programs in North America found that youth with the poorest outcomes at six months post-treatment had the fewest relapse coping strategies and skills.

Emrich (as cited in Bergmann et al. 1995) found that continued therapy and aftercare following completion of in-patient treatment have been predictive of successful treatment outcome. Family support in the recovery process was also strongly associated with post-treatment success. However, Bergmann et al. (1995) noted that family involvement in treatment must be individualized to meet client needs:

Family participation, in general, is a very important predictor of positive outcome. A structured "one-size-fits-all" family program, however, will never realize its potential effect on treatment outcome. Among certain subgroups of males, the primary family issues on which to focus should revolve around parental substance use, issues of abuse, and establishing behavioural parameters while living at home to facilitate recovery. For females, the family program may be most effective if it is centred around issues of self-esteem, anxiety and providing a supportive environment for recovery. (Bergmann et al., 1995:469)

In a meta-analysis and literature review, Stanton and Shadish (as cited in Weinberg et al., 1998) supported the superiority of family therapy (as opposed to family psychoeducation or support groups) for youth in treatment. Joanning et al. (1992) noted the effectiveness of structural-strategic family therapy (SSFT) which involves all family members, whether or not they are involved in treatment. Other integrated models (multi-dimensional family therapy) have also demonstrated treatment success. Azrin et al., (1994), in a controlled group study, found that cognitive-behavioural approaches (including therapist modelling, rehearsal, self-recording and written therapy assignments, stimulus and urge control and social control/contracting) were associated with post-treatment success.

Although Spooner et al. (1996) acknowledged a lack of research defining effective treatments, on the basis of a review of 17 studies, they concluded that:

Treatment strategies tend to favour family therapy, skills training and cognitive-behavioural therapy, all of which appear to have some effect on treatment outcome. With family therapy, however, not all adolescents have sufficient support from their families to facilitate treatment outcome, thus diminishing the value of this form of treatment for some adolescents. (Spooner et al., 1996:6 - 14)