Modern addiction treatment was developed to meet the needs of middle-aged men (Sanders, 2011). As the years have passed the addiction field has begun to pay more attention to the needs of various populations including adolescents, women, persons with co-occurring disorders, and people of color. Only over the past seven years has emphasis been placed on the behavioral health needs of emerging adults, meaning individuals between the ages of eighteen and twenty-five. This article outlines the unique treatment needs of emerging adults with substance use disorders.
Developmental Tasks of Adolescence
Substance use has the ability to delay the stages of development (Kinney, 2014). When emerging adult are in addiction treatment, special emphasis should be placed on helping them achieve main developmental tasks. Some of the tasks includes:
- Greater independence in their relationship with parents or legal guardians
- Developing independent living skills (i.e., moving out of their parents’ home, finding an apartment, securing employment, budgeting, and saving money)
- Increased problem solving skills
- High school graduation
- Establishment of a healthy relationship with a peer group
- Selection of a career goal
- Becoming more socially responsible
- Acquiring a set of values to guide their behavior
Increased Recovery Capital and Decreased Problem Severity
Research reveals that as recovery capital increases and problem severity decreases recovery rates increase (White & Cloud, 2008). Recovery capital is defined as internal and external resources that a person can bring to bear on their recovery. This includes success prior to addiction, internal optimism and hope, a quality education, cultural pride, love and support, employability, vocational skills, and prosocial group activities (White, Kurtz, & Sanders, 2005).
High problem severity includes co-occurring disorders, learning challenges, medical complications, traumatic stress disorder, and a lack of family and social support, among other things. In regards to specialized addiction treatment for emerging adults, emphasis should be placed on addressing and reducing the impact of problem severity while simultaneously increasing recovery capital via development of specialized services which increase recovery capital and/or linkage agreements with programs and communities that address these needs including GED and other educational programs, vocational schools, linkage to Twelve Step group meetings and other mutual aid groups.
Not all emerging adults are motivated for total abstinence, and even those who are motivated for abstinence have a high potential for relapse. Continued substance use among emerging adults increases the risk of developing HIV and other sexually transmitted diseases, hepatitis C, drug overdoses, and conviction of a felony.
Harm reduction can be instrumental in helping emerging adults stay safe as they make the decision whether or not they want to abstain from substance use. Examples of harm reduction include:
- Not sharing needles or cookers
- The use of Narcan
- The use of condoms and other safe-sex practices
- Staying out of cars with strangers
- Never mixing any drug with alcohol
- Adjusting the time of day and days of the week that they use drugs in order to reduce the negative impact of drug use on academic performance, employment, and relationships
- Decreasing or eliminating the use of one substance while continuing to use another
- Educating themselves of the harmful effects of various drugs they are thinking about trying
- Avoiding an adult felony conviction
Evidence indicates that receiving a felony conviction has longer term consequences than a substance use disorder (Hart, 2014). While people may recover from their addiction, in some states the consequences of a felony conviction can linger years after recovery. In some states if people receive a felony they cannot vote, receive public assistance, receive government loans to go to college, and work in numerous fields.
Evidence-Based Practices that are Emerging-Adult-Friendly
Many emerging adults are resistant to counseling for a number of reasons. They have histories of adult maltreatment and a premature entry into adulthood which means they often think, “What can a therapist tell me? I am grown too.” Some of them have been harmed in previous therapy and resistant to adult authority, which is a natural part of adolescent development. It is recommended that treatment providers working with emerging adults utilize evidence-based practices which allow clients to make positive life changes while maintaining autonomy simultaneously. Recommended practices include the following.
With this approach emerging adults are in charge of what, when, and how to change. Therapists walk alongside of emerging adult clients to help facilitate that change process (Miller & Rollnick, 2012).
The Use of Motivational Incentives
The use of motivational incentives has been found to be effective in substance use disorder treatment with all age groups. Specifically, the fish bowl technique in which emerging adults are able to draw raffle tickets from a fish bowl and win small, medium, large or the grand prize for certain target behaviors. These behaviors can include individual counseling attendance, group counseling attendance, active participation in group therapy, negative drug screens, attending educational classes, and others. The use of motivational incentives can motivate emerging adults to actively participate in programing while still denying that they have a substance use disorder. This approach can be effective in reducing resistance to change and increasing programmatic attendance (Sanders, 2011).
Integrated Dual Disorders Treatment
The great majority of persons with substance use disorders have a concurrent mental illness (Mueser, Noordsy, Drake, & Fox, 2003). The three types of co-occurring treatment are concurrent, sequential, and integrated. The integrated approach is most effective as emerging adults can get their clinical needs met in one setting at the same time. An effective integrated co-occurring disorders program allows emerging adults to decide which disorder they want to address first and allows them a menu of options to choose from in terms of the wellness strategy.
Behavioral Couple’s Therapy
With this evidence-based approach, therapists work with emerging adults and their spouses/ partners in helping them work together to maintain their recovery. The spouses/partners make a commitment to self-care and ways of which they will support their chemically dependent partner’s recovery. The chemically dependent partners make a commitment as to how they will maintain their recovery. With this approach both partners have a voice in the development of the plan.
The majority of clients seeking substance use disorders treatment have histories of trauma which often precede their substance use. Many are medicating the symptoms of the trauma with the use of alcohol and other drugs (Maté, 2010). Addiction treatment can be threatening to emerging adults, particularly if that treatment is seen as a threat to removing the one thing that they are using to medicate and numb the pain of trauma: alcohol and other drugs. A manualized, trauma-informed curriculum such as Seeking Safety and cognitive behavioral approaches can be instrumental in helping the emerging adult address their substance use disorder and trauma simultaneously.
Alternative Therapies and Materials
The use of art, music, dance, and drama is recommended for emerging adults. These creative therapeutic modalities can create a fun atmosphere, which is important for eighteen- to twenty-five-year-olds. Educational videos and other audio and visual materials should utilize actors and pictures of emerging adults. People tend to pay closer attention to information if they see images of themselves reflected in the material.
Culturally Specific Services
Services should be tailored to meet the specific needs of individuals and their culture. Addiction professionals should pay close attention to micro-aggressions. Micro-aggressions are intentional and unintentional slights which if unaddressed can serve as barriers to engagement. These slights could be based upon race, gender, sexual orientation, age, and other factors. It is the responsibility of clinicians to address micro-aggressions throughout their work with clients, because unaddressed the micro-aggressions can cause a rupture in the clinical relationship.
Family of Origin Work
All people seeking addiction recovery come from families, and yet family-focused work is one of the most neglected aspects of addiction treatment. With emerging adults, traditional family therapy, which may focus on how the emerging adults’ substance use disorder impacts parents and other family members, may be counterproductive. Such an approach may lead emerging adults to feel angry or hostile and will unintentionally keep them in the role of adolescent as the parents scold them for what they have been doing wrong. One of the developmental tasks of emerging adults is to develop independence from their parents. One goal of family-focused work would be to help emerging adults develop differentiation of self in their family of origin. That is the ability to develop healthy boundaries when the family of origins natural tendency may be to keep them stuck and enmeshed. To accomplish this, family-focused therapy with emerging adults may mean having separate meetings with the emerging adult which focuses on how they will develop increased independence or interdependence in their family of origin while simultaneously meeting separately with their parents with a focus on how to avoid enabling, self-care, and the establishment of healthy boundaries in their relationships with emerging adults.
This intervention occurs in the natural environment and there are three phases.
1. Pretreatment Engagement
Seventy-five percent of chemically dependent people will never seek help for their addiction (Sanders, 2011). There is a movement occurring in the addiction field where recovery coaches are being utilized to provide outreach to chemically dependent people who would not ordinarily seek treatment voluntarily. This is an important intervention for emerging adults. Many of them have not hit rock bottom, and therefore see no need to seek help. Also because this age group is at a high risk of overdose death due to opiate use, pretreatment engagement in the natural environment can be helpful in increasing their motivation to seek help.
2. In-Treatment Engagement
With this level of engagement recovery coaches try to build a relationship with emerging adults while they are receiving residential or outpatient services prior to discharge. The purpose of in-treatment engagement is to create a seamless system of care between treatment and the community.
3. Posttreatment Recovery Support
Research reveals that 80 percent of relapses occur within the first ninety days of people leaving treatment (White, 2005). Many emerging adults will return to a peer group that is actively using. There are a number of ways in which recovery coaches can help emerging adults deal with the fragility of early recovery including:
- Helping emerging adults disengage from a drug using peer group
- Linking emerging adults with resources in the community including shelter, food, educational programs, and medical clinics
- Helping emerging adults engage in communities of recovery such as Twelve Step groups, faith-based organizations, and secular programs of recovery
- Helping emerging adults through high-risk situations that exist within their communities that increase the risk of relapse
A few years ago I was invited to do a consultation for a residential treatment facility that was having a difficult time retaining emerging adults in treatment; 100 percent of them left treatment against medical advice during the previous six months. We brainstormed methods of increasing retention for this population. The first recommendation was that they needed a new medical director—one who had experience tapering emerging adults off of opiates. Their previous medical director had experience working with men in their forties and fifties with alcohol use disorders. Over the next six months we made other programmatic changes tailored for emerging adults including establishing a young people’s Twelve Step group meeting, outings that reflected the interests of emerging adults, the use of YouTube videos, and others. With these additions retention rates dramatically increased. This suggests the importance of tailoring treatment to the unique needs of clients served.
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Kinney, J. (2014). Loosening the grip: A handbook of alcohol information (11th ed.). New York, NY: McGraw-Hill.
Maté, G. (2010). In the realm of hungry ghosts: Close encounters with addiction. Berkeley, CA: North Atlantic Books.
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Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, NY: The Guilford Press.
Sanders, M. (2011). Slipping through the cracks: Intervention strategies for clients with multiple addictions and disorders. Deerfield Beach, FL: Health Communications.
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