Research reveals that the great majority of adolescents in addiction treatment do not believe they have a substance use disorder and are usually not in treatment under their own volition (Sanders, 2011). This leads to automatic resistance to counseling. Nearly 60 percent of adolescents miss their second outpatient session and over 50 percent drop out of residential treatment prematurely or are administratively discharged (Sanders, 2011).
This article will introduce an approach to adolescent recovery that is cost effective and evidence-based.
The site for the group intervention is a social service agency that offers an array of services to youth and families in Chicago, Illinois. The agency is a residential facility that provides a safe, nurturing treatment home with therapeutic support to youth, adolescents, and young adults. The agency also provides housing, academic, financial, and career support, as well as individual, family, and group therapy to all residents. In addition, the agency also has an aftercare program providing ongoing support to former residents and their families.
The great majority of clients in this setting are between the ages of thirteen to twenty-one and meet the criteria for complex trauma or posttraumatic stress disorder (PTSD). Other diagnoses include major depression, dysthymia, conduct disorder, bipolar disorder, and schizophrenia. Clients with mental illness and co-occurring disorders can meet with the agencies consulting psychiatrist for a psychiatric evaluation, medication evaluation or recommendation for hospitalization if warranted. Each youth receives services from a multidisciplinary team consisting of a supervisor, therapist, advocate, and educational consultant. Approximately 20 percent of the clients served meet the DSM-5 criteria for substance use disorders (APA, 2013). These are the youth who receive specialized services for substance use disorders.
The primary intervention is a substance use disorders therapy group which integrates various evidence-based approaches including the cannabis youth treatment (CYT) study, motivational incentives, the matrix model, meditation, and recovery checkups. A description for each approach follows along with a rationale for its use.
The Cannabis Youth Treatment (CYT) Study
The CYT study was the first intervention selected. This group intervention combines motivational interviewing with cognitive behavioral therapy with the goal of reducing adolescent marijuana use (Dennis et al., 2004). This approach has a great deal of efficacy with adolescents. There have been multiple trials with positive outcomes in terms of reduction in adolescent marijuana use (Dennis et al., 2004).
This intervention was selected because the primary drug of choice for adolescents in the group is marijuana, although most report a history of other drug use ranging from cocaine, alcohol, Xanax, molly, and ecstasy.
There are four curricula as a part the CYT study (a manualized approach), and we decided to integrate volumes one and two. Combined they consist of two individual sessions followed by ten consecutive weekly group meetings. These curricula were selected based upon NIDA research which reveals that twelve weeks of recovery support is considered an effective therapeutic dosage (White, 2005).
This intervention was selected to integrate with the CYT study. Research indicates that motivational incentives have been effective in increasing programmatic retention, attendance, and reducing resistance to counseling (Breda & Heflinger, 2004). We specifically utilized the fish bowl technique; at the end of each group members were allowed to draw raffle tickets from the fish bowl as incentives and positive reinforcement.
There are 250 raffle tickets in the fish bowl with the following value attached to each:
- 125 tickets: “Keep up the good work.” There is a 50 percent chance that a youth will not win a prize. This is backed by research which suggests if one can win too easily, the reinforcer loses value (Breda & Heflinger, 2004).
- 50 tickets: “You win a small prize.” (Value approximately $5)
- 50 tickets: “You win a medium prize.” (Value approximately $10)
- 24 tickets: “You win a large prize.” (Value approximately $15–$20)
- 1 ticket: “You win the grand prize.” (Value $75–$100 which is a gift certificate to a popular store for adolescents such as Nike or Forever 21)
The prizes are in the group room and youth are able to retrieve them immediately, as research indicates that immediate reinforcers are most effective (Corby, Roll, Ledger, & Schuster, 2000). Prizes ranged from electronic equipment, video games, gift certificates, athletic wear, and others. All the prizes were donated to the program and was therefore a cost-effective intervention.
Attendance was over 90 percent over the course of the twelve weeks and resistance was at a minimum. According to research, adolescents who receive motivational incentives are less resistant to therapy as they are able to tell themselves they don’t have a problem, but they will gladly work for the incentives (Breda & Heflinger, 2004).
In the group we incentivized punctuality (members started arriving at 7:30 PM for an 8:00 PM group), active participation, and positive leadership. Other behaviors which can be incentivized include negative drug screens, consecutive groups attended, and academic success.
Additional Evidence-Based Practices
The group has been led on both the adolescent male and female campuses. Integrating the CYT study with motivational interviewing for the first group. Each time the group was offered we added additional evidence-based practices including the matrix model, meditation, and recovery checkups.
The Matrix Model
The matrix model is a sixteen-week, outpatient treatment program that teaches early recovery skills and relapse prevention (Rawson et al., 1995). The matrix model has been shown to significantly decrease the amount and frequency at which individuals were using substances following treatment (Rawson et al., 1995). Elements of the matrix model were incorporated into the group curriculum midway through the ten-week term in response to group acknowledgement of few sober social supports, being triggered by boredom and unanimous desire to gain early recovery skills. Group topics facilitated include coping with boredom, increasing social supports, and relapse prevention planning. The matrix model can be downloaded at the Substance Abuse and Mental Health Services Administration (SAMHSA) store website: www.store.samsha.gov.
It has been predicted that clients who meet the DSM criteria for substance use disorders would get younger (Sanders, 2011). By our third time leading the group members dropped in average age from sixteen to twenty-one to thirteen to fourteen. This younger group generally had more anxiety and engaged in more slapstick comedy and horseplay. One of the group leaders introduced meditation exercises at the beginning of each group in order to help members regulate emotions, get grounded, and relax. We would periodically intersperse brief meditation exercises in the middle and towards the end of the group as needed. According to members, this low cost intervention was quite helpful. Clients stated, “I feel relaxed now,” “I’m sleepy,” or “I feel calmer.”
Mindfulness meditation exercises encourage participants to become aware of the present moment including their thoughts, sensations, consciousness, and bodily states (Hofmann, Sawyer, Witt, & Oh, 2010). Participants are encouraged to take a nonjudgmental approach, noticing and accepting thoughts, feelings, emotions, and experiences rather than judging or trying to change them (Hofmann et al., 2010). Mindfulness meditation was incorporated into the treatment program to provide intentional time to allow the youth to relax, regulate, and learn to recognize their thoughts, urges, and emotions without judgment. Mindfulness meditation exercises were initiated into the group cycle in order to help youth regulate, focus, and cope with their high energy levels during group. Studies have shown the benefits of such interventions including improved cognitive functioning, self-esteem, decreased anxiety, improvements in self-regulation and self-control, and reductions in behavioral issues (Wisner, Jones, & Gwin, 2010). Exercises utilized within the intervention focused on body awareness, the use of their five senses, thoughts, emotions, and urges. Progressive muscle relaxation and visualization were additional mindfulness exercises utilized within the intervention.
Recovery Checkup Group
Research reveals that recovery checkups can be instrumental in increasing recovery rates (Dennis & Scott, 2012). One reason medical doctors have an 85 percent recovery rate is because they are monitored via recovery checkups for five years’ postacute care treatment.
With the aforementioned research in mind, the group leaders decided to provide a monthly recovery checkup group on both the male and female campuses. The group has met once a month for over two years. It is offered to all youth who complete the twelve-week group.
Results of the Intervention
Feedback from group members and the results of drug screens reveals the following:
- 80 percent of the group members reduced their marijuana use during the twelve-week support group.
- 80 percent of the adolescent females and 50 percent of the adolescent males remained totally drug free during the twelve weeks they participated in the group.
- The adolescent females in the recovery checkup group currently average 1.5 years of abstinence and 80 percent of them are headed to college.
- Average length of recovery in the adolescent male recovery checkup group is approximately two months. More research is needed to understand the reason the recovery rates among the adolescent females is much higher than the males. One factor may be their longer duration of involvement in the program and the group.
- There were group members who were unable to complete the twelve-week group due to the need for a higher level of care.
- 100 percent of members indicated that they would recommend the group to a peer.
Other feedback from group members:
- “The group increased my confidence that I could stop getting high.”
- “I now believe that I no longer have to escape from my problems by getting high.”
- “Before this group I thought I could only have fun high. We had a lot of fun in this group drug free.”
This group has been effective in keeping adolescents engaged in addiction treatment long enough to receive an effective therapeutic dosage. Twice a year we bring the entire community together for a recovery celebration.
We have had experiences facilitating the group that are funny and inspiring. One youth discussing the use of motivational incentives stated, “They bought my recovery.” She has remained drug free for fifteen months. Another youth won the grand prize and decided that he would let newer youth take the prize. It seems that gratitude for his recovery was reward enough.
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