1 Working with Adolescents with Substance Use Disorders Michael S. Levy, Ph.D. CAB Health & Recovery Services, Inc. Health and Education Services 8% of 12-17 year old youth have substance abuse or dependence 13.7% of 12-17 year old youth have experienced at least one major depressive episode; 8.8% experienced a major depressive episode within the last year. Of the 8.8% who experienced a major depressive episode within the past year, 38% had used illicit drugs. Among youth who have not experienced a major depressive episode, only 18% used an illicit drug Among youth who experienced a major depressive episode within the last year, 19.8% had illicit drug or alcohol dependence. Among youth who did not experience a major depressive episode within the past year, only 6.9% had illicit drug or alcohol dependence. Among youth diagnosed with illicit drug or alcohol abuse or dependence, 21.7% experienced a major depressive episode Among youth not diagnosed with illicit drug or alcohol abuse or dependence, only 7.7% experienced a major depressive episode. National Survey on Drug Use and Health 2005 600 adolescents entering outpatient treatment for marijuana abuse and dependence were assessed using the GAIN. Youth reported acute levels of conduct disorder (74%), ADHD (77%), depression (38%), anxiety (29%), and traumatic stress (14%). The Relationships Between Psychopathology and Substance Psychopathology is a significant risk factor and can lead to substance use and addiction. The authors concluded by saying that co-occurring distress is the norm for adolescents seeking outpatient services for marijuana disorders. Diamond, et al., 2006
Does Psychopathology Lead to Substance Abuse? Studied youth with or without bipolar illness at an average age of 13 years old. It was found that youth with bipolar illness was associated with an increased risk of substance use disorder (32% vs. 7%). This relationship was found to be independent of conduct disorder. Wilens et al., 2004 Does Psychopathology Lead to Substance Abuse? Studied 428 children aged 12 years old and who were free from substance use. Assessments were conducted for three years. The most significant predictive factors for adolescent substance use disorder were male gender, ADHD, conduct disorder, and sibling use of tobacco. The authors concluded that early intervention for disruptive behavior disorders would be important to prevent substance use disorders in early adolescence. Gau et al., 2007 Does Psychopathology Lead to Substance Abuse? Looked at 142 ADHD youth and compared them to 100 youth without ADHD. Assessed prospectively from ages 13-18. Found that youth with ADHD reported higher levels of alcohol, tobacco, and illicit drug use than did youth without ADHD. Severity of inattention predicted multiple substance abuse outcomes. The development of conduct disorder in youth with ADHD was associated with the highest levels of substance use. Molina and Pelham, 2003. Does Psychopathology Cause Drug Use? 506 boys were followed from ages 13-18 Substance use was assessed, as was ADHD, oppositional defiant disorder, conduct disorder, history of violence and depression. Higher levels of all of the types of psychopathology predicted higher levels of alcohol use. Higher levels of ADHD, conduct disorder, and violence predicted higher levels of marijuana use. Conduct disorder seemed to predict a steeper rise in alcohol use. Does Psychopathology Cause Drug Use? The Relationships Between Caveats It is possible that to some degree, substance use could have caused some of the psychopathology or at least worsened it as some youth were using marijuana and using alcohol at an early age. Substance use and addiction can cause psychopathology. It is also possible that both psychopathology and drug use was caused by other factors such as parental alcoholism or other genetic factors. Study focused only on males White et al., 2001 2
3 Does Drug Use Cause Psychopathology? Substance use intoxication can look like a psychiatric disorder. Withdrawal from substance dependence can look like a psychiatric disorder. Substance use causes problems that can lead to a psychiatric disorder or at least to difficult mental states. Does Drug Use Cause Psychopathology? 736 subjects were interviewed at ages 14, 16, 22 and 27 years old. Depression and drug use were measured. Findings: Adolescent and young adult tobacco use was associated with an increased risk of alcohol dependence and substance use disorders, but not with major depression. Earlier alcohol use predicted later major depression, alcohol dependence and substance use disorders, as did early marijuana use and other illicit drug use. Except for tobacco use, early drug use was significantly related to later psychiatric disorder, even after controlling for age, sex, parental education level, family income and prior episodes of major depressive disorder and substance use disorders. Does Drug Use Cause Psychopathology? In summary, early drug use is associated with and predicts later psychiatric disorders. Should be noted that relationship is not necessarily causal; yet, substance use appears to contribute to the occurrence of depression. Also interesting that all drugs had similar effect; perhaps this arises from unmeasured common underlying factors as family conflict, genetic factors, or drug-using peers. Brook et al., 2002 The Relationship Between Cannabis and Psychosis Many studies have shown that rates of psychosis and schizophrenia are higher among those with a history of cannabis use. Early use of cannabis appears to increase the risk of psychosis. A dose-related effect was seen among: Individuals who used cannabis during adolescence. Those who had previously experienced psychotic symptoms. Those at high genetic risk for developing schizophrenia. Cannabis appears to be an independent risk factor for psychosis and psychotic symptoms, but many who use cannabis never develop psychosis. Those with a positive genetic loading for schizophrenia and psychosis have a greater risk. Semple et al., 2005 The Relationships between The Relationships Between Substance abuse and Psychopathology can become meaningfully linked to each other over time. Substance Abuse and Psychopathology can be caused by some other problem.
4 The Relationships Between Psychopathology and substance use affects the course and recovery of each illness. Psychopathology Affects Substance Use Outcome Compared youth with a co-occurring psychiatric disorder to youth without such a disorder (N-992) across 23 adolescent drug treatment programs including residential, short-term inpatient, and outpatient. Assessed at baseline and 12 months after treatment. Youth with co-occurring disorders, often a conduct disorder, were more likely to be drug or alcohol dependent and had more problems with family, school, and the legal system, and this held true at follow up. Comorbid youth made greater reductions in problem behaviors, but this may be a function of higher levels of problematic behaviors at intake. At follow up, cormorbid youth had higher use of marijuana and hallucinogens, more legal problems and arrests, and among depressed youth, greater rates of suicidal symptoms. Grella et al., 2001 Psychopathology Affects Substance Use Outcome Looked at treatment outcome of 126 13-18 year old adolescents with co-occurring substance use and psychiatric disorders, and compared this to 81 youth with no co-occurring psychiatric disorder. Youth with co-occurring psychiatric disorders received more treatment; despite this, more youth with co-occurring psychiatric disorders used more substances than youth without a co-occurring disorder. Youth with more than one co-occurring psychiatric disorder were more likely to relapse than those with fewer disorders and had more alcohol and drug dependence diagnoses both before and after treatment. Tomlinson, Brown, and Abrantes, 2004 Dangers When Mental Health Professionals Work with Youth with Substance Use Disorders The client s substance use is not fully addressed and made a focus of treatment. Substance use is not fully appreciated in the client s distress. Insight becomes the focus of clinical work. A direct approach is not utilized. Dangers When Substance Abuse Professionals Work with Youth with Mental Health Concerns A client s pain is not fully addressed and acknowledged. Psychiatric diagnoses are under-diagnosed. Medication is under-utilized. Inflexibility of treatment planning. Counter-Transference Concerns Discouragement Anger Frustration Hyper-vigilance Hyper-investment Omnipotence Hopelessness We must remember that we are not responsible for the client s recovery or relapses and that we have no control over the client s drug use.
5 Working with Youth with Substance Use Consequences Take Time to Occur Substance Use is Highest in young Adulthood Some Mature Out of It We Have No Control Confrontation Model Point out and insist to the person that he or she has an alcohol or drug problem. Point out the negative consequences caused by their addiction. Educate them that they have a disease and they they must achieve abstinence. Tell people what they need to do to achieve to start feeling better. Confront and attack denial. If they are not ready for treatment, tell them this and that they can come back when ready for treatment. Motivational Model Accept that ambivalence about changing is normal and to be expected. Accept people where they are. People may be at different stages of readiness to change; however, they can be worked with at all stages of change. Confrontation is prohibited. Find out what people want and work with their treatment goals. Stage of Change Model Pre-contemplation Contemplation Preparation Action Maintenance Termination The TEEACH Model Building the Therapeutic Alliance T - Therapeutic Alliance Building E - Exploring the positive aspects of substance use E - Exploring the negative aspects of substance use. A - Ambivalence C - Central conflict H - Delivery of Hope Work to develop a friendly, non-threatening relationship. Talk about what the client wants to talk about. Avoid focusing on the client s chemical use. Ask questions about chemical use in a matter-of-fact, non-judgmental way. Established treatment goals need to be the client s.
6 Explore the Positive Aspects of Substance Use Discover what clients like about using chemicals. Ask about chemical use when the timing is right; this will decrease defensiveness. Show a sincere interest in how chemicals help the client. Inquire what high means for the client. Empathize and fully appreciate the solution. Explore the Negative Aspects of Substance Abuse Do this only after you have first acknowledged the positives. Do not rush into this. Ask in an inquisitive, off-handed way, not to prove to the client that there are negative consequences. Be mindful of lip service. Get to the affect: The consequences must be meaningful to the client. Highlight the solution and how it helps. You may need to wait. Ambivalence and the Central Conflict Chemical use is both a solution and a problem. Clients must come to appreciate this and learn to sit with this ambivalence. Acknowledging this will continue to strengthen the therapeutic relationship. The Mantras: Chemical use is a short fix, but a long term problem. As much as I want to use, I can choose not to in order to avoid the harmful consequences of using. The Delivery of Hope Clients often feel that there is no other way to cope. No hope about ever feeling better. The idea of stopping chemical use is overwhelming. Despair must be countered. Give the message that they can achieve what chemicals do for them through healthier and less destructive ways. Change is absolutely possible. Psychopharmacology General Principles Other Thoughts Substance abuse is a great mimicker of psychiatric illness. Evaluate the person when drug-free! Effects of some substances can last long after intoxication and withdrawal. Effects of substance abuse can last long after intoxication and withdrawal. If psychosis persists after several days, treat it with appropriate medication. Can always stop the medication afterwards. Don t Over-react! Chemical Use Falls Along a Continuum Engagement is Key Is Moderation Possible?
7 To Successfully Work With Youth with Substance Use Disorders: To Successfully Work With Youth with Substance Use Disorders: Develop a relationship Conduct a careful assessment Engaging them into treatment is key and change may take time Psychopharmacology may be important Clients must come to see that using chemicals, while it is a solution, is also a big problem Clients must come to see that they will never feel better in the long run as long as chemical use continues Clients must come to see that there may be other ways to get their needs met Clients must be given hope Therapists must not lose hope