Therapists, clinicians and substance-abuse counselors question why more and more adolescents who enter treatment for drugs and alcohol return to the use and lifestyle of the addiction, and subsequently back into treatment. Based on recent studies of adolescent substance abuse, adolescents are influenced to use and abuse drugs by a number of factors pertaining to youth, cognitive structure, family relations, peer associations, school performance and neighborhood context. Because of this, broad-based prevention and treatment strategies are needed to address multiple aspects of these teens’ cognitive processes and ecology.

Past prevention and treatment approaches usually addressed only some of the reasons for drug abuse by teens and have often provided services such as hospitalization or traditional outpatient care, which have little bearing upon the adolescent’s natural environment.

What research shows about adolescent drug use

Studies strongly support that adolescent drug use, problem drug use and drug-use patterns (relapse) following treatment, is determined by the interplay of characteristics of the individual youth and the key social systems in which the adolescents are embedded. These systems include the family and peers, school and neighborhoods.

More recent reviews, (Hawkins, Catalano and Miller 1992; Office of Technology Assistance 1991), show that the following correlates of adolescent drug use and abuse occur most consistently.

Individual: Other antisocial behaviors, low self-esteem, low social conformity, psychiatric characteristics, expectations of positive effects from drugs, genetic influence.
 

Family: Ineffective management and discipline, low warmth and high conflict, parental drug abuse.
 

Peer: Association with drug-using peers, low association with pro-social peers.
 

School: Low intelligence, achievement and commitment to achievement.
 

Neighborhood: Disorganization, high crime.

These associations represent the systems with which adolescents interact. They interface and are interactive with each other and clearly find:

1. Association with drug-using peers was always a powerful and direct predictor of adolescent drug use.
2. Family relations directly predicted drug use.
3. School difficulties predicted association with drug-using peers. Prevention and treatment of adolescent substance abuse

Clinicians and therapists, in devising prevention and treatment programs for adolescents, need to expand their basis for determining the cause of drug use and abuse, to include other factors along with the disease model. Hawkins, in a 1992 article, stated, “If a primary goal of intervention is to weaken the probability of drug abuse, prevention efforts should focus on weakening the impact of risk factors that enhance protective factors (e.g., family and extra-familial support).”

Adolescent alcohol and drug treatment programs should address the known determinants and their related problems while promoting the strengths of adolescents and their systems.

Prevention

Three prominent and effective approaches to prevention for adolescent substance abuse can be drawn from several reviews in the past five years that examined drug-abuse prevention literature prepared by Botvin, Schinke and Orlandi in 1989; another by Felner, Silverman and Adix in 1991, and other researchers including Hawkins, 1992; Kumpfer, 1989; Office of Technology Assessment 1991; Newcomb and Bentler, 1989.

(1.) Focus on high-risk youth. A high priority should be given to the
development of effective interventions for adolescents that are most likely to present grave economic, criminal and social problems linked with drug abuse. Because the determinants of drug abuse are generally the same as the determinants of delinquency, school dropout and unprotected sexual activity, the development of effective comprehensive prevention programs can have many additional benefits to participants and to society.

(2.) Early prevention. Many experts have urged drug-abuse prevention specialists to address risk factors that occur in early and middle childhood, before the initiation of drug use. Several types of interventions from research already demonstrate effectiveness regarding the weakening of established risk factors and the development of protective factors. Appropriate childhood programs should include early childhood and family support programs, parenting programs and programs that promote academic achievement through tutoring and restructuring school environments.

(3.) Multisystemic approach is an intensive family- and community-based treatment that addresses the multiple determinants of adolescent substance use and abuse, and serious antisocial behavior in juvenile offenders. This therapy treatment strives to promote behavior changes in the youth’s natural environment, using the strengths of each system to create change.

This type of Multisystemic therapy focuses on long-term outcomes by empowering caregivers to manage future difficulties. Its ultimate goal is to empower the adolescent’s primary caregivers with skills and resources needed to independently address the difficulties that arise in youths that engage in or are dependent on substance use and abuse, and to empower them to cope with family, peers, school and neighborhood problems. Multisystemic therapy focuses on changing the known determinants of substance use and abuse, including characteristics of individual youth, the family and peer relations, school functioning and the neighborhood. Family, child and community resources create these changes. It is effective in minimizing out-of-home placements, assisting families and in reducing incarcerations, inpatient and residential placements.

In Multisystemic Treatment of Antisocial Behavior in Children and Adolescents, Scott Henggeler and colleagues list and explain nine treatment principles that can also be used with adolescents who use and abuse drugs and alcohol.

Principle 1: The primary purpose of assessment is to understand the fit between problems and their broader systemic context.

The goal of multisystemic assessment is to make sense of behavioral problems in light of their systemic context. Consistent with social-ecological models of behavior, multisystemic treatment assessment focuses on understanding the factors that contribute directly or indirectly to behavioral problems. These features pertain to transactions between the child and his or her environmental surroundings. The clinician or therapist attempts to determine how each factor, singularly, or in combination, increases or decreases the probability of adolescent substance use or abuse.

Principle 2: Therapeutic contacts emphasize the positive and use systemic strengths as levers for change.

The successful treatment of adolescent substance use and/or abuse is contingent upon engaging the family in treatment collaboration and developing a supportive, therapeutic alliance. However, working with families with problems that may include child abuse and other serious issues can cause a host of negative emotions including frustration, hopelessness and anger, which can be an obstacle in the therapist’s or clinician’s capacity to engage the family in a strong therapeutic alliance. An emphasis on strength-focused attitudes and interactions enhances staff morale and most likely improves family-level outcomes for several reasons.

• Sets the stage for cooperation and collaboration by decreasing the annoying effects of negative influence and builds feelings of hope and positive expectations, which are linked with favorable outcomes.

• Helps to identify protective factors such as family resources and social supports, that lead to the development of better informed interventions and to solutions that have increased ecological validity and can be sustained by the family over time.

• Decreases therapist and family frustration by emphasizing problem solving (e.g., focusing on how desired changes can happen as opposed to why problems are so bad).

Principle 3: Interventions are designed to promote responsible behaviors and decrease irresponsible behaviors among family members.
To achieve the positive results associated with multisystemic treatment (reductions in substance abuse, out-of-home placement, arrests and improvements in family functioning), clinicians and therapists assist parents and youth to behave responsibly across a variety of domains. They do this by promoting parental and youth-responsible behavior and working to decrease irresponsible behavior such as substance use and abuse.

Principle 4: Interventions are present, focused and action-oriented, targeting specific and well-defined problems.

The overall purpose of this treatment principle is to encourage family transactions that facilitate clinical progress toward clear outcomes.

Principle 5: Interventions target seq-uences of behavior within and between multiple systems that maintain the identified problems.

This is an interesting principle in that it orients the practitioner toward modifying those aspects of family relations and of the social ecology that are linked with identified problems. One of the salient features of multisystemic treatment and a characteristic that differentiates multisystemic treatment from the vast majority of treatment models is the significant attention devoted to transaction between systems that are associated with identified problems.

Principle 6: Interventions are developmentally appropriate and fit the developmental needs of the youth.

Children and their caregivers have different needs at different periods of their lives, and interventions should be designed in consideration of these needs. In designing such individual interventions, however, the clinician must consider the youth’s level of cognitive and social development.
The developmental stage of the caregiver is also an important factor when designing interventions. A primary example is grandparents who are thrust into the role of primary caretakers, who may have different developmental needs than a traditional parent.

Principle 7: Interventions are designed to require daily or weekly effort by family members.

Designing interventions that require routine effort provide several advantages:

(1.) Identified problems can be more quickly resolved if everyone involved is working on them.

(2.) Backsliding and disregarding treatment protocols become readily apparent. Consequently, clinicians can respond immediately to identify and address barriers to change.

(3.) Treatment outcome can be assessed continually, which provides many opportunities for corrective actions.

(4.) Because intervention tasks occur daily, family members have frequent opportunities to receive positive feedback in moving toward goals, praise from therapists and others in the ecology and satisfaction inherent in completing tasks. Such reinforcements promote family motivation and maintenance of change.

(5.) Family empowerment is supported as families learn that they are primarily responsible for and capable of progressing toward treatment goals.

Principle 8: Intervention effectiveness is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes.

This principle ensures that the therapist will have a continuous and relatively accurate view of treatment progress and therefore receive ongoing and prompt feedback regarding the effectiveness of interventions. Multiple informants and multiple methods should be used to evaluate the ongoing effectiveness of interventions. Informants can include parents, the youth, siblings, teachers, peers, classmates, neighbors and other professionals working with the family.

Principle 9: Interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts.

Designing interventions that promote treatment generalization and maintenance is an active process that has the following important implications for the clinician:

(1.) Emphasize the development of skills that family members will use to direct their social ecology

(2.) Develop the capacity of family members to negotiate current and future problems.

(3.) Be delivered primarily by caregivers with therapists playing primarily supportive and consultative roles.

(4.) Emphasize and build family strengths and competencies.

(5.) Overuse of protective and resil-iency factors available in the natural environment.

Systems-level changes

The following system changes are recommended to ensure that adolescents receive effective treatment.
Reduce the use of restrictive services.

• Increase the availability of home- and community-based services.
• Increase provider accountability.
• Increase service integration.
• Reform mechanisms for financing services.
• Train providers in the delivery of clinically effective, cost-effective services.
• Services should be flexible and individualized.
• Therapist and clinician responsibilities

Therapist characteristics and behavior are vital in maintaining a strength-focused approach when working with substance-abusing adolescents.

(1.) Encourage therapists, supervisors and administrators to use language that is not pejorative. Instead of viewing clients as resistant, see them as a challenge.

(2.) Teach and use techniques of re-framing. This helps clients not to focus on blame.

(3.) Use positive reinforcement liberally. Therapists and clinicians should strive to find evidence of client effort and improvement — regardless of how small — and positively reinforce them.

(4.) Incorporate and maintain a problem-solving stance. A problem-solving stance emphasizes the examination of factors that increase the probability of success, as opposed to determining what fails.

(5.) Provide hope. It is difficult to provide hope if therapists do not have hope that) somehow, some way, things can change or be different.

(6.) Find and emphasize what the family does well. The therapist should focus on identifying and encouraging what the family does well. To ease this process, it is useful to break large, seemingly insurmountable tasks into small steps.

A multisystemic approach to adolescent substance use and abuse is clinically sound, research based, and definitely reduces out-of-home placements. It is also valuable because it places a strong emphasis on the family. For, how do we help adolescent? We help them by helping the family.

Fred J. Dyer, MA, CADC, is a speaker, trainer and consultant to social service agencies, organizations and corporations on the subjects of chemical dependency, violence and other mental health issues, especially as they affect adolescents and their families.

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