Psychosocial issues

People involved with the justice system typically have many problems related to employment and financial support, housing, education, transportation, and unresolved legal issues. Many inmates have not completed high school or earned a general equivalence diploma. Only about 55 percent were employed full time before their incarceration (Bureau of Justice Statistics 2000).

Medical and psychiatric problems

Offenders with a substance use disorder may have co-occurring psychiatric disorders. Approximately 16 percent of State inmates, 7 percent of Federal inmates, and 16 percent of jail inmates and probationers reported having mental illnesses, and nearly 60 percent of these offenders reported that they were under the influence of alcohol or drugs at the time of their offenses (Ditton 1999). People in prison have a high incidence of HIV/AIDS (Maruschak 2002), tuberculosis, sexually transmitted diseases, and hepatitis C (National Institute of Justice 1999).

Female offenders

Between 1990 and 2000, the number of women involved with the justice system (incarcerated, on probation, or paroled) increased by 81 percent (Bloom et al. 2003). Women accounted for 15 percent of the total correctional population in 1998; 90 percent were under community supervision (Glaze 2003; Harrison and Beck 2003). Seventy-two percent of the women in Federal prisons were convicted of drug offenses or committed their crimes while under the influence of drugs or alcohol (Greenfeld and Snell 1999). Female offenders with substance use disorders experienced more health, educational, and employment problems; had lower incomes; reported more depression, suicidal behavior, and sexual and physical abuse; and had more mental and physical health problems than did male offenders with substance use disorders (Langan and Pelissier 2001). More than half the female inmates in prisons had at least one child younger than 18 (Mumola 2000). The National Institute of Corrections' Gender-Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders (Bloom et al. 2003) provides more information about female offenders.

Double stigma

Offenders often are affected by the stigma associated with involvement in the justice system, as well as the stigma associated with substance abuse. These two factors can impede an offender's ability to obtain appropriate employment or housing.

Violence

Women with substance use disorders are more likely than men with substance use disorders to have been physically or sexually abused as children (Bartholomew et al. 2002; Simpson and Miller 2002). In addition, women who have a substance use disorder are more likely to be victims of domestic violence (Chermack et al. 2001), with reported rates of women in treatment who have been victims of physical and sexual violence ranging from 75 percent (Ouimette et al. 2000) to 88 percent (B.A. Miller 1998).

Mental disorders

Compared with men, women with substance use disorders have nearly double the occurrence (30.3 percent vs. 15.7 percent) of serious mental illness and past year substance use disorders (Epstein et al. 2004). These higher rates of psychiatric comorbidity are particularly evident in mood and anxiety disorders (Zilberman et al. 2003).

Parenting issues

Women in treatment often bear the sole caretaking responsibility for their children, and this role can be a substantial obstacle to seeking and remaining in treatment. Women may have difficulty finding reliable and affordable child care. They may fear losing custody of their children because of their substance use, and this fear may deter them from entering treatment. At the same time, women (and men) who abuse substances are more likely to abuse or neglect their children (National Clearinghouse on Child Abuse and Neglect Information 2003).

Welfare issues

Some States require that individuals receiving welfare benefits be screened and treated for substance use disorders; failure to enroll in or dropping out of treatment may jeopardize benefits (Legal Action Center 1999). Such requirements can help retain a client in an IOT program, and a case manager should coordinate treatment with welfare staff.

Pregnancy

Substance use during pregnancy can mean poor prenatal care, unregistered delivery, and low-weight and premature babies (Howell et al. 1999). Heavy or binge alcohol or drug use during pregnancy can result in negative consequences for the child such as neurological damage, including fetal alcohol syndrome (American Academy of Pediatrics 2000).

Relationships

A woman's substance use disorder is often influenced by her partner. Women with male partners who use substances are retained in treatment for a shorter time than women with substance-free partners (Tuten and Jones 2003). Conversely, a woman's partner can have a positive influence on treatment through support and participation in treatment.

Barriers to treatment entry and retention

Once a woman decides to seek help, she may face a long wait because of the lack of appropriate treatment. In addition, she faces gender-specific barriers and issues that may affect entry and retention in treatment such as

• Concerns about fulfilling her responsibilities as a mother, wife, or partner
• Fears of retribution from an abusive spouse or partner
• Gender and cultural insensitivity of some treatment programs
• Threat of legal sanction, such as loss of child custody
• Lack of affordable or reliable child care
• The disproportionate societal intolerance and stigma associated with substance abuse in women compared with men
• Ineligibility for treatment medications if she is pregnant or may become pregnant
• Having few other women in treatment with her

Entry and assessment

A woman entering treatment needs to feel that the environment is safe and supportive. IOT program staff members who are understanding, respectful, optimistic, and nurturing can build a positive, therapeutic relationship. It may help if the intake counselor is a woman. The client may be fearful, confused, in withdrawal, or in denial, and staff members need to be patient and supportive, understanding that it is empowering for the client to choose when to provide information and what information to provide. Additional ways to facilitate entry include providing help with child care and extending program hours for working women.

Using a comprehensive assessment, staff members can identify the client's strengths and weaknesses and work with her to develop specific treatment goals and a treatment plan. Because of the likelihood of victimization and presence of co-occurring psychiatric disorders, female clients need careful assessments for psychiatric disorders and history of childhood trauma and adult victimization. Chapter 5 discusses intake forms that can be used or modified to gather these data. Victimization experiences may be hidden beneath shame and guilt but, as trust develops, the client can discuss these events.

Treatment components specific to women

Exhibit 9-1 identifies core clinical needs and service elements that should be addressed in IOT for women (CSAT 1994d ).

It is important to identify issues that the client is uncomfortable discussing in a group setting. As a woman feels more comfortable, she may be able to discuss them. Relapse prevention techniques may need to be modified for women. There is some evidence that women's relapses are related to negative mood, more so than men's (Rubin et al. 1996). Also, women may do better in women-only counseling groups (Hodgins et al. 1997).

Therapeutic styles

Women who abuse substances may benefit more from supportive therapies than from other approaches and need a treatment environment that is safe and nurturing (Cohen 2000). Safety includes appropriate boundaries between counselor and client, physical and emotional safety, and a therapeutic relationship of respect, empathy, and compassion (Covington 2002).

For women with low self-esteem and a history of abuse, harsh confrontational approaches may further diminish their self-image and retraumatize them. Less aggressive approaches based on understanding and trust are more likely to effect change (Miller and Rollnick 2002). The confrontational approach of “breaking down” a person in treatment and rebuilding her as a recovering person may be overly harsh and not conducive to treating women (Covington 1999).

Woman clients can be referred to mutual-help groups such as Women for Sobriety and 12-Step groups that are sensitive to the needs of women. Some areas have women-only Alcoholics Anonymous (AA) and Narcotics Anonymous meetings, and some groups provide onsite child care. A Woman's Way Through the Twelve Steps (Covington 1994) and its companion workbook can help women adapt the 12 Steps for their use (Covington 2000).

Considerations for domestic violence survivors

IOT providers need to consider the safety of the client, develop and implement a personal safety plan for her, and notify the proper authorities if she is in danger. TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT 1997b ), provides additional information.

Treatment for pregnant women

Because of the possible harm to fetuses, it is important to provide comprehensive treatment services to pregnant women who abuse substances. IOT has produced positive results for pregnant women, and retention in treatment is facilitated by provision of support services such as child care, parenting classes, and vocational training (Howell et al. 1999). Elements of one model program for pregnant women include (CSAT 1993a ; Howell et al. 1999)

• A family-centered approach with pregnancy and parenting education and mother-child play groups
• Interdisciplinary staff
• Counselor continuity
• Physical and mental health services
• Child care and transportation services
• Housing services that address homelessness or unstable and unsafe housing conditions

Other programs have found that being flexible and responsive to clients' needs and using nonconfrontational approaches improve the health of the women and newborns (Whiteside-Mansell et al. 1999).

Group characteristics

When a client has co-occurring disorders, both the client and IOT counselor are presented with many challenges, such as

• Interacting symptoms that complicate treatment
• Increased biopsychosocial disruptions such as increased family problems, violent victimization, financial instability, homelessness, incarceration, suicidal ideation or attempts, and medical problems

Barriers to accessing treatment

Most people with co-occurring mental and substance use disorders are not receiving appropriate care (Watkins et al. 2001). Two of the numerous barriers to treatment are limited access to treatment and poor coordination between treatment systems.

In addition, historically, substance abuse and psychiatric treatments were provided in separate settings, and it was believed that one disorder must be stabilized before the other disorder could be treated, resulting in fragmented services. Clients were caught between two systems (Drake et al. 2001). The different treatment approaches led to misunderstandings between mental health and substance abuse treatment providers. Mental health providers may use more motivational and supportive techniques and professionally trained staff, whereas substance abuse treatment programs use more confrontational approaches, which may be distressing for clients with co-occurring disorders, and often combine peer support with professionally trained counselors (Minkoff 1994). Some substance abuse treatment providers and recovering peers still may harbor antimedication attitudes and not understand the benefit of psychotropic medications.

Integrated treatment

For the past two decades, integrated treatment has been proposed as an effective treatment approach. Minkoff (1994) presents a theoretical framework that considers both disorders chronic, primary, biologically based mental illnesses that are likely to be lifelong, but he suggests that conjoint treatment could reduce symptoms of both disorders effectively and promote recovery. His general treatment principles follow:

• Recognize that the basic elements and processes of addiction treatment are the same for clients who have a psychiatric disorder as for those without one.
• Include education, empathic confrontation of denial, relapse prevention, and involvement with both professional- and peer-led groups.
• Modify standard substance abuse treatment by simplifying interventions, accommodating cognitive limitations if necessary, adapting step or group work, and using mutual-help groups for people with co-occurring psychiatric disorders.
• Develop interventions specific to each phase of treatment.
• Provide comprehensive services that cover treatment of both disorders.

In a review of the literature on treating substance use disorders and co-occurring schizophrenia, Drake and colleagues (1998b ) found that integrated treatment, especially when delivered for 18 months or longer, resulted in significant reduction in substance abuse and, in some cases, in substantial rates of remission, reductions in hospitalizations, and improvements in other outcomes. Many IOT programs do not treat clients with serious mental disorders such as schizophrenia on a regular basis and do not have the advantages of the programs cited in Drake and colleagues' review (e.g., intensive case management, 18-month treatment window). Charney and colleagues had similar success treating clients with co-occurring depression over a 6-month period (2001). Treatment retention and outcome improved when psychiatric services were provided at the substance abuse treatment facility.

Integrated treatment coordinates substance use and mental disorder interventions to treat the whole client and

• Recognizes the importance of ensuring that entry into one system provides access to all needed systems
• Emphasizes the association between the treatment models for mental disorders and addiction
• Advocates the concomitant treatment of both disorders
• Follows a staged approach
• Uses treatment strategies from both the mental health and substance abuse treatment fields

Conceptual framework

The National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors, with support from the Substance Abuse and Mental Health Services Administration (SAMHSA), developed a conceptual framework of four quadrants to classify service coordination and help providers categorize treatment according to the severity of symptoms of both disorders (see exhibit 9-2) (Substance Abuse and Mental Health Services Administration 2002).

Figure

Exhibit 9-2. SAMHSA's Service Coordination Framework for Co-Occurring Disorders.

Clients in category I often are identified in primary care, educational, or community settings and may need consultation services for prevention and early intervention services. Clients in categories II and III generally present or are referred for treatment for their more severe disorder—either mental or substance use disorder—often leaving them with little or no care for the other disorder. These clients may be referred to IOT programs, and care requires collaboration between mental health and IOT providers. Clients in category IV generally need comprehensive, integrated treatment (Substance Abuse and Mental Health Services Administration 2002).

Core treatment needs and service elements

ScreeningAll clients need to be screened for co-occurring psychiatric disorders to determine whether they have signs and symptoms warranting a comprehensive psychological assessment. These signs and symptoms may be subtle, and clients may minimize or deny symptoms because of fear of stigma.

AssessmentA thorough assessment should be performed either by a clinician trained in both areas or by clinicians from each field. On occasion, symptoms of acute or chronic alcohol and drug toxicity or withdrawal can mimic those of psychiatric disorders. The client should be observed closely for worsening conditions that warrant transfer to a more appropriate facility or to determine whether treatment for withdrawal symptoms is needed. Conversely, substance abuse can mask psychiatric symptoms, which may appear during the initial stages of abstinence. Programs should be organized around the premise that co-occurring disorders are common; assessment should proceed as soon as it is possible to distinguish the substance-induced symptoms from other independent conditions. Particular attention should be paid to the following:

• Psychiatric history of the client and family including diagnoses, previous treatment, and hospitalizations
• Current symptoms and mental status
• Medications and medication adherence
• Safety issues such as thoughts of suicide, self-harm, or harming others
• Severe psychiatric symptoms that result in the inability to function, communicate effectively, or care for oneself

This information can be augmented by objective measurement with assessment tools such as those described in the TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e ).

Many programs have rigid guidelines for the initial mental health assessment and evaluation, including the initial psychopharmacology evaluation, such as requiring a certain length of abstinence. Programs should be flexible about assessment, removing these barriers when possible. Similarly, denial of access to evaluation or treatment for a substance use disorder because an individual is taking a prescribed psychotropic medication is inappropriate. Clients should continue taking medication for a serious mental disorder while being treated for their substance use disorders (Minkoff 2002).

Treatment engagementSome clients with co-occurring psychiatric disorders, especially severe disorders, may have difficulty committing to and staying in treatment. Providing continuous support and outreach, assisting with immediate problems (such as housing), monitoring individual needs, and helping clients access services help develop a therapeutic treatment relationship. In the absence of such support, clients with co-occurring psychiatric disorders may be at high risk for dropping out (Drake and Mueser 2000).

Treatment planningFactors to consider when developing a treatment plan for these clients include the client's psychiatric status, housing, social support, income, medication adherence, and symptom management. By understanding the client's strengths and goals, IOT program staff can develop a treatment plan that is consistent with the client's needs. Regular reassessments monitor the client's progress in both conditions and are the basis for adjustments to the treatment plan. Increased individual sessions and smaller group sizes also are indicated.

ReferralClients with psychiatric disturbances that require secure inpatient treatment setting, 24-hour medical monitoring, or detoxification (such as clients who are actively suicidal or hallucinating) should be referred to a facility equipped to provide appropriate care. The American Society of Addiction Medicine provides placement criteria for clients with co-occurring psychiatric disorders (Mee-Lee et al. 2001).

Mental health care

Any IOT program that serves a significant number of clients with co-occurring psychiatric disorders should include mental health specialists and psychiatric consultants on the treatment team.

Prescribing psychiatristIt is ideal to have a psychiatrist with substance abuse treatment expertise on site to provide assessment and treatment services, on a full-time, part-time, or consultant basis (Charney et al. 2001). This approach overcomes problems with offsite referral such as the client's lack of transportation and the difficulty of working with another agency. However, when funding or other constraints prohibit providing mental health care services on site, other options are (1) employing a master's-level clinical specialist who can treat clients, consult with other staff members on mental disorders, and function as the liaison with psychiatric consultants or (2) establishing a working relationship with a mental health care agency to provide onsite care.

Medication provision and monitoringAppropriate psychotropic medications are essential. Pharmacological advances over the past decade have resulted in medications with improved effectiveness and fewer side effects. Psychotropic medications stabilize clients, control their symptoms, and improve their functioning. The IOT program counselor can

• Refer the client to a psychiatrist or other mental health care provider for treatment evaluation.
• Help arrange appointments with the mental health care provider and encourage the client to keep them.
• Become familiar with common psychotropic medications, their indications, and their side effects.
• Instruct the client on the importance of complying with the medication regimen.
• Report symptoms and behavior to the prescribing psychiatrist and other staff members to assist in the determination of medication needs.
• Use peers or peer groups to monitor medication and to support the client's proper use of medication.
• Monitor side effects.

A helpful resource is Psychotherapeutic Medications 2003: What Every Counselor Should Know (Mid-America Addiction Technology Transfer Center 2000).

Collaboration with mental health care agencies

If circumstances prevent the provision of mental health care services in the IOT program, a collaborative relationship with a mental health agency can be established. One way to form this relationship is through an MOU that ensures that psychiatric services are adequate and comprehensive. The MOU specifies referral procedures, responsibilities of both parties, communication channels, payment requirements, emergency contacts, and other necessary procedures. TIP 46, Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT 2006f ), provides more information about setting up formal mechanisms for working with other agencies.

Case management services provide assistance with service coordination when clients with co-occurring disorders require treatment in two or more systems of care. TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT 1998a ), provides extensive details about case management.

Modified program structure

Treating clients with co-occurring psychiatric disorders in an IOT program often necessitates modifying the program structure or approach.

Separate treatment tracks in IOTSeparate tracks for clients with both disorders allow clients to be grouped together to address issues pertinent to them in group sessions. This arrangement particularly helps clients with severe co-occurring psychiatric disorders. Establishing a separate track may entail organizational change as the agency modifies its scheduling, staffing, and training needs.

Staged approachesStaged approaches provide successive interventions geared to the client's current stage of motivation and recovery and address varying levels of severity and disability of the co-occurring disorders (Drake et al. 1998a ; Minkoff 1989). The model developed by Osher and Kofoed (1989) includes four overlapping stages—engagement, persuasion, active treatment, and relapse prevention—that integrate treatment principles from both fields. The model advocates treatment components consisting of low-intensity, highly structured programs; case management services; provision of appropriate detoxification; toxicology screening; family involvement; and participation in mutual-help groups. Other staged approaches are described in Minkoff (1989) and Prochaska and DiClemente (1992).

Working with clients with co-occurring psychiatric disorders

When mental and substance use disorders co-occur, both disorders require specific and appropriately intensive primary treatment and need to be individualized for each client according to diagnosis, phase of treatment, level of functioning, and assessment of level of care based on acuteness, severity, medical safety, motivation, and availability of recovery support (Minkoff 2002).

The treatment of clients with substance use and high-severity psychiatric disorders (schizophrenia or schizoaffective disorder) differs from the treatment of clients who have anxiety or mood disorders and a substance use disorder. Clients with severe disorders often are the most difficult to treat. Examples of approaches that attempt to integrate and modify psychiatric and substance abuse treatments to meet the needs of the client are (1) a skills-based approach, (2) dual-recovery therapy, (3) assertive community treatment, and (4) money-management therapy (Ziedonis and D'Avanzo 1998).

The treatment of clients with substance use and mood or anxiety disorders incorporates approaches such as cognitive-behavioral therapy, which addresses both disorders. Several other components, such as relaxation training, stress management, and skills training, are emphasized in the treatment of both types of disorders (Petrakis et al. 2002).

Some clients may have cognitive deficits that make it difficult for them to comprehend written material or to comply with program assignments. Materials can be adapted to express ideas and concepts simply and concretely, incorporating stepped assignments and using visual aids to reinforce information. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998e ), provides more information on accommodating clients with disabilities.

The therapeutic relationship

Establishing a trusting, therapeutic relationship is essential during the engagement process and throughout treatment. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e ), suggests the following guidelines for developing a therapeutic relationship with clients with both disorders:

• Maintain a belief that recovery is possible.
• Manage countertransference.
• Monitor psychiatric symptoms.
• Provide additional structure and support.
• Use supportive and empathic counseling.
• Use culturally appropriate methods.

The clinician's ease in establishing and maintaining a therapeutic alliance is affected by comfort with the client. IOT program clinicians may find working with some clients with psychiatric illnesses unsettling or feel threatened by them and may have difficulty forming a therapeutic alliance with them. Consultation with a supervisor is important, and with experience, training, supervision, and mentoring, the problem can be overcome.

Confrontational approaches may be ineffective for clients with co-occurring psychiatric disorders because they may be unable to tolerate stressful interpersonal challenges. When counseling clients with co-occurring psychiatric disorders, it is helpful if the counselor is empathic and firm at the same time. By setting limits on negative behaviors, counselors provide structure for clients. Another assertive intervention involves counselors' supplying feedback that consists of a straightforward and factual presentation of the client's conflicting thoughts or problem behavior. Provided in a caring manner, such feedback can be both “confrontive” and caring. The ability to do this well is often critical in maintaining the therapeutic alliance with a client who has co-occurring psychiatric disorders (see chapter 5 in TIP 42 [CSAT 2005e ]). TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999c , p. 41), provides more information.

Clients with co-occurring psychiatric disorders may become demoralized and despairing because of the complexity of having two disorders and the slow pace of improvement in symptoms and functioning. Inspiring hope is a necessary task of the IOT program clinician. Some suggestions include

• Demonstrating an understanding and acceptance of the client
• Helping the client clarify the nature of his or her difficulties
• Communicating to the client that the clinician will help the client help himself or herself
• Expressing empathy and a willingness to listen to the client
• Assisting the client in solving external problems immediately
• Fostering hope for positive change

Group treatment

Group treatment, a mainstay of IOT, is used widely and effectively with clients with co-occurring disorders (Weiss et al. 2000), including clients with schizophrenia (Addington and el-Guebaly 1998). Several approaches can be used: 12-Step based, educational, supportive, and social skills improvement. These group interventions have demonstrated success in increasing treatment engagement and abstinence rates and decreasing the need for hospitalization (Drake et al. 1998a ). Some examples of groups follow:

• Psychoeducational groups increase clients' awareness of both problems in a safe and positive environment.
• Psychiatric disorders groups present topics such as signs and symptoms of mental disorders, use of medications, and the effects of mental disorders on substance use problems.
• Medication management groups provide a forum for clients to learn about medication and its side effects and help the counselor develop solutions to compliance problems.
• Social skills training groups provide opportunities to learn how to handle common social situations by teaching clients to solicit support, develop drug and alcohol refusal skills, and develop effective strategies to cope with pressures to discontinue their prescribed psychiatric medication. Group participants role play situations and practice appropriate responses. Reinforcing the difference between substances of abuse and treatment medications is another simple but important activity of these groups.
• Onsite support groups are led by an IOT staff facilitator and provide an arena for discussing problems and practicing new coping skills.

Group treatment may need to be modified and augmented with individual counseling sessions for clients with both disorders. The clients' ability to participate in counseling depends on their level of functioning, stability of symptoms, response to medication, and mental status. Some clients cannot tolerate the emotional intensity of interpersonal interactions in group sessions or may have difficulty focusing or participating. Many clients with a serious mental illness (schizophrenia, schizoid and paranoid personality) have difficulty participating in groups but can be incorporated gradually into a group setting at their own pace. Clients with less severe psychiatric disorders may have little problem participating in group sessions. Some suggestions for working with groups of clients with co-occurring disorders include

• Orally communicate in a brief, simple, concrete, and repetitive manner.
• Affirm accomplishments instead of using disapproval or sanctions.
• Address negative behavior rapidly in a positive manner.
• Be sensitive and responsive to needs of the client.
• Shorten sessions.
• Organize smaller groups.
• Use more focused, but gentle directional techniques.

Mutual-help groups in the community

The consensus panel encourages the use of “double trouble” mutual-help recovery groups for people with co-occurring psychiatric disorders. Because all attendees have a co-occurring psychiatric disorder, they are less likely to be subject to the misunderstanding and conflicting messages about their psychiatric symptoms or use of psychotropic medications that sometimes occur in traditional 12-Step-oriented groups (Magura et al. 2003). These groups do not provide clinical or counseling interventions; members help one another achieve and maintain recovery and be responsible for their personal recovery.

Various dual recovery organizations have been established by people in recovery and usually are based on the AA model but adapted for people with both disorders, including

• Double Trouble in Recovery (www.doubletroubleinrecovery.org)
• Dual Disorders Anonymous
• Dual Recovery Anonymous (www.draonline.org)
• Dual Diagnosis Anonymous

The research on traditional 12-Step groups is not definitive, but attendance at such groups may be beneficial for some clients with co-occurring psychiatric disorders (Kelly et al. 2003). However, clients with severe mental disorders may have difficulty attending these groups (Jordan et al. 2002). Some people with co-occurring disorders attend both dual disorder and traditional mutual-help groups (Laudet et al. 2000b ). In one study, most AA respondents had positive attitudes toward people with co-occurring disorders and 93 percent indicated that such individuals should continue taking their psychotropic medications (Meissen et al. 1999). AA has published The A.A. Member—Medications and Other Drugs (Alcoholics Anonymous World Services 1991), a helpful booklet that discusses AA members' use of medications when prescribed by a physician knowledgeable about alcoholism (visit www.alcoholics-anonymous.org to order).

Relapse prevention

In addition to learning techniques to prevent relapse to substance abuse, clients with co-occurring psychiatric disorders may benefit from learning to recognize worsening psychiatric symptoms, manage symptoms, or seek support from a “buddy” or a mutual-help group. Some providers suggest that clients keep “mood logs” to increase their awareness of how they feel and the situational factors that trigger negative feelings or symptoms. Other techniques include affect or emotion management, including how to identify, contain, and express feelings appropriately. Several relapse prevention interventions for clients with both disorders have been developed (Evans and Sullivan 2000; Weiss et al. 2000).

Other issues

Family education and supportClients with co-occurring disorders frequently have unsatisfactory relationships with their families. Some clients with psychiatric disorders remain dependent on their families for an extended period, creating complicated family dynamics. Other clients may be estranged from or have strained relationships with family members, partners, or children. Groups for family members can be a venue for education and support. Psychoeducation combines fundamental information, guidance, and support and allows for low-key engagement and continued assessment opportunities. Family members and significant others need to understand the implications of both disorders and the ways that one disorder, if not properly monitored and treated, can worsen the symptoms of the other.

At times more intensive family intervention may require removing clients from stressful family relationships and helping them toward independence. Some families may be in need of intensive family therapy and should be referred for appropriate care.

Peer networksDeveloping supportive peer networks to replace friends who use substances is an important component of recovery and needs to be addressed in treatment. When a client's family is not supportive, other, more supportive networks can be sought.

Discharge planning and continuing care

Because people with co-occurring psychiatric disorders have two chronic conditions, they often require long-term care that supports their progress and can respond quickly to a relapse of either disorder. Some clients may need to continue intensive mental health care but can manage their substance use disorder by participation in support groups. Other clients may need minimal mental health care but require some form of continued formal substance abuse treatment. Participation in continuing care tends to improve treatment outcomes (Moggi et al. 1999).

Developmental changes

Adolescence is a period characterized by physical, emotional, and cognitive changes. Developmental tasks include the many transformations that move adolescents from childhood to adulthood. Physical changes include rapid growth, development of secondary sex characteristics, and fluctuations in hormonal levels. Cognitively, adolescents often have shorter attention spans than adults, have limited perspectives on the future, may be inconsistent in applying abstract thinking skills, and may be impulsive. During adolescence, morals, values, and ideals continue to develop, and intellectual interests expand. During late adolescence, youth become more introspective and sensitive to the consequences of their actions (CSAT 1999f ) and improve their capacity for setting goals.

Development of substance abuse in adolescents

Many factors are associated with the onset of substance use problems in adolescents including genetic background, parental substance use and troubled family relations, individual characteristics such as cognitive dysfunction, and to some extent peer influence (Weinberg et al. 1998). Risk factors for developing a substance use disorder include a history of personality problems such as aggression or an affective disorder, school failure, distant or hostile relations with parents or guardians, family disruption, or a history of victimization (Weinberg et al. 1998).

Family assessment

The adolescent's family consists of the main caregivers (usually parents) and anyone the client considers family. Family issues to assess include family structure and functioning, financial and housing statuses, substance use history and treatment episodes, mental and physical health, the family's feelings about the adolescent, and family members' problems with violence and involvement in the legal system. The strengths and resources available to the family need to be identified as well. IOT program staff members may want to interview the adolescent in private initially and then meet with family members.

Psychiatric assessment

Every client can benefit from a thorough psychiatric assessment by a mental health professional trained in adolescent care. As many as 60 percent of adolescents with a substance use disorder also have co-occurring psychiatric disorders (Armstrong and Costello 2002), such as anxiety, mood disorders (Kandel et al. 1999), or attention deficit/hyperactivity disorder (Weinberg et al. 1998). Adolescents should be assessed for suicide risk as well.

Diagnosis

Although some adolescents may meet the diagnostic criteria for substance dependence, many are in the early stage of involvement with alcohol or drugs. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association 2000) does not contain diagnostic criteria specific to adolescent substance dependence, and some adult diagnostic criteria, such as withdrawal symptoms and alcohol-related medical problems, present differently in adolescents. For these reasons, the DSM criteria have limitations when applied to adolescents (Martin and Winters 1998).

Family involvement

Because outpatient family therapy may offer benefits superior to other outpatient treatments (Williams et al. 2000), IOT providers are encouraged to work with the family as much as possible. Chapter 6 on family therapy in this TIP and TIP 39, Substance Abuse Treatment and Family Therapy (CSAT 2004c ), provide more information.

Engaging the familyThe IOT counselor can engage family members by

• Emphasizing how critical family members are to the adolescent's recovery
• Requiring (whenever possible) that a family member accompany the adolescent to the initial intake interview and including time for the family assessment during that meeting
• Encouraging family attendance at the program's family education and therapy sessions
• Helping family members participate in developing and reinforcing the behavioral contract (see below)
• Supporting family members in encouraging the adolescent to attend treatment

Treatment of the familyFamily-oriented interventions have long been used to treat adolescents who abuse substances. Szapocznik and colleagues (1983, 1986) helped establish the effectiveness of family therapy in treating adolescents. The premise of family therapy is that the family plays a role in creating conditions leading to adolescent drug use and that family elements help adolescents recover (Liddle et al. 2001). Evidence shows that youth who receive family therapy have less drug use at treatment completion than those who receive peer group therapy or whose families participate in parent education or a multifamily intervention (Liddle et al. 2001).

Some family-based approaches are as follows:

• Multidimensional family therapy and multisystemic therapy expand classic family therapy models to focus on promoting change in four areas: (1) the adolescent, (2) family members, (3) family interaction patterns, and (4) influences from outside the family (Liddle 1999, 2002).
• Family cognitive-behavioral therapy integrates traditional family systems theory with techniques of cognitive-behavioral therapy. This approach considers adolescent substance abuse as a conditioned behavior that is reinforced by cues and contingencies within the family (Latimer et al. 2003).
• The adolescent community reinforcement approach focuses on teaching adolescents coping skills and changing environmental influences related to continued substance use (Godley et al. 2001).
• The family support network intervention increases parental support of an adolescent's recovery through developing a support group for parents, provides home therapy sessions combined with group sessions, and can be used with any standard adolescent treatment approach (Hamilton et al. 2001).
• The family intervention program (see exhibit 9-3) addresses many problems experienced by families with an adolescent who uses substances. It includes the family and systems that affect the family, such as schools and the community.

Exhibit 9-3. The Family Intervention Program

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This approach partners a family therapist with a community resource specialist. The specialist helps the family establish healthy community networks. Working as a team, the therapist and specialist conduct five family therapy sessions and perform the following:

1. Assess the family system; explore the family's resources, concerns, and goals; and create a treatment plan.

2. Explore relationships among family members, identify areas of difficulty and stress, and determine the effect on the family system.

3. Determine the effect of other systems, such as schools, on the family.

4. Focus on the family's concerns and goals and include others who can help resolve problems.

5. Work on how the family can resolve issues without staff help and develop a followup plan.

Source: Fishman and Andes 2001

The behavioral contract

Adolescents who abuse substances may behave in disruptive, destructive, or sometimes criminal ways, such as skipping school, having poor school performance, violating curfew, being argumentative with or withdrawing from family members, joining gangs, or committing crimes.

To address these behaviors, a behavioral contract can be a valuable therapeutic tool. The clinician works with the adolescent (and his or her family) to develop a contract that specifies treatment goals, acceptable and unacceptable behaviors, and the rewards or consequences associated with each.

The conditions defined in the contract help the youth and the family understand the treatment process and what is expected of them. Once the contract is completed, the client and each family member indicate their agreement by signing the contract. IOT program staff uses the contract to guide discussions during family group sessions, to monitor progress, and to minimize the undermining of treatment by family members.

Case management services for adolescents

The IOT provider may need to provide extensive case management services. The case manager works with schools to monitor a youth's compliance with the behavioral contract; coordinates medical, mental health, and social services; and works with the juvenile justice system, if needed. Caseloads are best kept to about 8 to 10 adolescents per staff member.

Group work strategies for adolescents

Treating adolescents involves bringing together youth from different areas, backgrounds, and developmental levels. Many practitioners recommend, if possible, that the groups consist of adolescents of the same gender, with similar levels of motivation for change, and of similar age. Clients in middle-to-late adolescence (ages 16 to 18) usually have different life experiences, developmental levels, and concerns than do younger adolescents. There is limited evidence of the effectiveness of treating adolescents in groups, perhaps because of the complexities just mentioned. The consensus panel reports that, with this population, approaches emphasizing structured discussions around a topic introduced by the counselor are more successful than open-ended sessions. Same-gender groups can provide a safe environment in which to explore such issues as sexuality, intimacy, self-esteem, and relationships. If programs do not have enough adolescent clients to have a treatment group, a gender-specific group session can be held weekly to discuss sensitive issues.

To foster productive group work, it is helpful to enforce clear, specific, concrete rules. IOT program staff can post the rules in the session room and ask each participant to sign a copy. Rules should prohibit bullying and teasing. Groups also commonly prohibit nostalgic stories of substance use.

Group members frequently are asked to sign a confidentiality statement promising that information shared in the group will not be repeated outside group. Other suggestions for treating adolescents in groups are

• Including activities and keeping discussions short
• Varying session content, activity level, and purpose
• Including frequent breaks

CSAT's Cannabis Youth Treatment Series offers many specific ideas for use with adolescents (Godley et al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl and Kadden 2001; Webb et al. 2002).

A co-counselor is helpful in running groups for adolescents because of the complexity of adolescent issues and behavior management challenges.

Clinical considerations

Providing incentives acknowledges the efforts of youth and encourages them to persevere. Incentives should be meaningful to the youth, such as gift certificates from a music store, movie theater, or clothing store.

Other key points about treating adolescents include the following:

• A cognitive-behavioral model and motivational enhancement techniques are useful.
• Not all adolescents who use substances are dependent, and prematurely diagnosing or labeling adolescents or pressuring them to accept that they have an addictive disease may not work.
• Many adolescents respond better to motivational interviewing than to confrontation.

Exhibit 9-4 lists characteristics and behaviors of adolescents in treatment and practical treatment suggestions.