There are several components of substance abuse treatment but for the sake of simplicity the focus of this article will be on three: intervention, treatment, and aftercare. Each of these categories have a number of elements, all of which are important to an individual’s chances of staying sober. An intervention requires the counselor to both recognize the critical issues creating the problem and the ability to communicate a viable course of action. Treatment involves individual, group, and family counseling. Aftercare is most important because this is the time when all other aspects come together to establish a sober way of life.
What Happens in Treatment?
In an outpatient program like Insight the time a person spends in treatment is usually about 12 weeks. This sounds like a considerable amount of time, but in reality there is a lot of information to pack in a short period. Most people don’t come into treatment with a tremendous amount of self-awareness and breaking through denial is an arduous process. Ultimately, the point of treatment is to establish a strong foundation for long term recovery. It is dangerous to expect a person with a drug/alcohol problem to be focused on issues outside of learning how to stay sober on a daily basis. A young person who is dependent on drugs and alcohol needs months of repetition to learn new and better coping mechanisms. This doesn’t mean life has to come to a complete halt but it does mean that expectations should be shifted. By the time someone is discharged from treatment there will be a clear plan of action on how to move forward in sobriety and in other areas of life.
What Happens in Aftercare?
Aftercare is where the rubber meets the road for a person in early sobriety. Through the course of treatment the recovering drug abuser has recognized the nature of his/her problem, become aware of the primary triggers that lead to using, and identified the relationships that have been harmed as the result of continuous drug and alcohol abuse. It takes time to develop a serious drug and alcohol problem and the destruction can be far-reaching. It takes much longer to clean up the mess and move forward. Most people in early recovery need several months (sometimes years) to change what has become a default mode of coping. In aftercare the newly sober individual has a specific plan of action and a lot of emotional support. In Insight the after-care and follow-up part of the program takes place over a two year period. Remember treatment usually lasts around 12 weeks. A person in aftercare continues individual counseling, support group meetings, and social functions while reintegrating into main stream life. The key is that this reintegration is as a sober person. This transition takes time.
When a young person enters drug and alcohol treatment most parents have (what seem to be) thousands of questions.
- What about school?
- How long will this take?
- What about vacation?
- Do I have to stop drinking?
- Is it my fault?
- What if he/she relapses?
- What will happen after treatment?
This list is by no means exhaustive but it provides some examples of what people want to know. The first piece of advice for anyone is…….breathe. Once the problem is uncovered most loved ones want immediate resolution. Unfortunately this is an issue that has been a long time in the making and the recovery process isn’t quick.
Commit to the Solution
Drug and alcohol treatment usually requires a serious financial and time commitment. Therefore, it is important to keep in mind to not take temporary for permanent. It won’t always be like this. The longer an individual stays sober, the more capable he or she becomes of taking on more responsibilities. In early recovery it is vital that sobriety be the top priority. This means before school, work, and Sunday family dinner. It’s not that these parts of life aren’t important, it’s that none of them will matter if an addict doesn’t stay sober. The objective of treatment is to help an individual navigate life without the use of drugs and alcohol. At a program like Insight that means abstinence. Throughout the course of treatment the newly sober person gains coping tools that will be used in aftercare. Taking the time to to internalize these tools as much as possible is vital.
The Big Picture
One of the primary goals of treatment for a young addict or alcoholic is family recovery. Once a young person is sober he or she is better prepared to participate in the family. It is extremely difficult to overcome the guilt and shame created by an addict’s lifestyle. Eventually the recovering addict wants to repair damaged relationships. It is a challenge for loved ones to wait for this transformation to take place. However, those who are able to maintain patience are usually rewarded.
Looking Back on 40 Years of Adolescent Substance Abuse Treatment
Steven L. Jaffe, MD, DFAPA, DLFAACAP
Professor Emeritus of Child and Adolescent Psychiatry, Emory University School of Medicine, Atlanta, GA
Clinical Professor of Psychiatry, Morehouse School of Medicine, Atlanta, GA
Clinical Director, The Insight Adolescent Drug Abuse Program
In 1972, while I was a fellow in child psychiatry at Emory University, I consulted at a methadone program where heroin addiction and crack cocaine were an inner city African-American problem. In the mid-1980s, I became involved in substance abuse treatment as the director of an Atlanta adolescent inpatient program. Half of my patients were involved in alcohol and drugs, and, at the time, I knew next to nothing about how to deal with this problem. My residency at the Massachusetts Mental Health Center (Harvard University) and my child and adolescent psychiatry fellowship at Emory University had done little to prepare me for work in this new field.
I decided to create a separate drug program for adolescents, hired an excellent counselor who was in good recovery, and we plunged ahead. Together we ran a substance-abuse group five days a week for four years. Today, based on that experience, I advise fellows in child psychiatry at Emory University School of Medicine to pick a sub-specialty that few know anything about; one can become an expert if you know just a little bit and build upon it.
In the 1980s, the main drugs abused by teenagers were alcohol, marijuana, LSD, crack and cocaine. My counselor took me to my first AA meeting, and we began to bring the adolescents in the program to meetings every week. I studied the history of AA, and as we were trying to apply the steps to teens, I wrote “The Step Workbook for Adolescent Chemical Dependency Recovery: a Guide to the First Five Steps.” This workbook modified the steps to make them developmentally appropriate for adolescents. At that time, the AACAP had a contract with APPI Press to publish recommended books. I submitted the workbook for review by the AACAP committee. Although two members of the committee approved it, two others declined. They thought that the AA steps, which were written in the late 1930s, were too religiously oriented and sexist (“God as we understand Him”). Fortunately for me, Mel Lewis, chair of the committee, cast the deciding vote to publish. Since it was published in 1990, 35,000 workbooks have been sold.
I learned about addiction on a personal level during the early 1980’s as I struggled to stop smoking. Nicorette gum was very helpful, and I have not had a cigarette in over 35 years. Still, I continue to have using thoughts and urges which demonstrates the power of the addictive process and believe that my understanding of addiction is confirmed by my own experience.
I regret to say that during that time period, people in the addiction field, including me, took a confrontational approach which we rationalized was necessary to break thru denial. While I never yelled at someone that he was an addict, I did take an aggressive position asking questions to have him/her admit how drugs and alcohol had negatively affected their life.
At the time I was directing daily community meetings for a hospital psychiatric program with 30 adolescents and staff. It was during that period that I was elected to be chairman of the Academy’s nominating committee. When I assertively chaired a meeting to choose a slate of national officers, one member supportively remarked “Oh, Jaffe was just acting like he was running his adolescent community meeting.” I directed that hospital program for 10 years with close to a 95% census and a relationship with Emory University School of Medicine in which we sponsored two residents/fellows every year.Shortly thereafter, there was a shake-up in the administration, and I was fired, and a few years later, the hospital closed.
I went on to direct another adolescent program in Atlanta, but that position was short-lived as the hospital was sold to an investor who wanted an immediate financial return and decided to cut staff. Then, in 1992, I went to a third hospital to direct their adolescent psychiatric program, and I again set up a separate substance abuse program. Since hospital length of stays were now a few weeks instead of a few months, I developed “the Adolescent Substance Abuse Intervention Workbook: Taking a First Step” which was also published by APPI Press.It solicits answers to short concrete questions as to the negative effects of alcohol/ drugs on 12 areas of an adolescent user’s life. The answers are presented and further explored in group therapy. This process corresponds to the First Step of AA and helps subjects move from precontemplation to contemplation. Unlike books on psychopharmacology, which quickly become out of date, these workbooks are still being used in a number of adolescent treatment programs.
After 10 years at this hospital, with length of stays now reduced to only a few days I was burnt out and left hospital psychiatry. I have continued teach at Emory and Morehouse medical schools along with the private practice I had started in the 1970s.
In 1998 I was fortunate to connect with a creative enthusiastic sobriety intensive outpatient adolescent/young adult substance-abuse program known as the Insight Program. A few years later I became their clinical director, and I continue in that position at the present time. This is a unique program of having fun without drugs and alcohol and consists of groups four hours a day, Monday to Friday, two evening groups where IOP patients connect with those in the aftercare program, and a weekly parents’ group. The uniqueness of the program lies in its provision of social activities every Friday night and Saturday night. The IOP lasts 12-15 weeks and aftercare, where the adolescents attend evening groups and the weekend social activities, continues for two years. Here I learned the importance of a loving empathic approach. The staff are cool, hip, young recovering drug addicts who clearly love what they do. They pay me a token amount, but my primary compensation is the love and good feelings of working with them.
While working in this modified 12-Step program, I became interested in understanding the spiritual (higher power) component. During the past several I years I have been interviewing young staff who are in good recovery, have completed the program and were training in the program’s counselor 12-week training program. After interviewing 72 young staff members, I compiled their stories, realizations and epiphanies in my recent book “Sacred Connections: Studies of Spirituality in Recovering Adolescent and Young Adult Substance Abusers” (available from Amazon books). Like the AA booklet “Came to Believe…,” which describes the variety of spiritual experiences in adult alcoholics working a 12-Step program, this book describes the spiritual struggles faced by substance abusing adolescents and young adults trying to seek a higher power. It is a tool for any program that uses or connects severe substance abusing youth to a 12-Step program.
Drugs of choice in the 1990’s were alcohol and marijuana, but Ecstasy, Molly, Ritalin, and Adderall were added to the mix. The methamphetamine epidemic began in the late 1990s and continued in the 2000s. Then, during the 2000s, the perils of substance use became more severe as opiate and benzodiazepine pills became popular. Beginning in 2005, physical dependence to opiate pills was widespread and led into the present epidemic of heroin addiction in suburban middle- and upper-class Caucasian populations.
Marijuana strength has increased tenfold, increasing its negative effects on cognition, anxiety and danger to driving. In addition, LSD and the use of research chemicals, including the synthetic cannabinoid Spice, is common. While in previous decades death in adolescents and young adults attributed to drug use was uncommon, in the current opiate epidemic, in which fentanyl is added to heroin, death due to overdose is no longer a rare phenomenon. For physicians and counselors, the stress of dealing with these patients has soared, as treatment becomes a daily life-and-death issue.
The high prevalence of drugs in the adolescent and young adult population makes it imperative for all child psychiatrists to become knowledgeable about substance abuse. I was delighted to see that at the recent AACAP meeting in Seattle, there were several presentations and an Institute on substance abuse and medical marijuana. Still, there has been a relative paucity of child and adolescent psychiatrists entering this field of treatment. In addition there are relatively few quality treatment programs for adolescents. Sending a teen to an expensive 30-day program without integrated intensive local follow-up treatment yields little success.
Child and adolescent fellowships need to provide more substance abuse treatment experience. I am especially pleased that Morehouse Medical School, which will begin a child and adolescent psychiatry fellowship in 2020, will have fellows spend two days a week for three months at the Enthusiastic Sobriety Program that I direct. Working with severe substance abusing youth challenges the psychiatrist with unique issues. Young abusers love their drugs, frequently relapse and are poorly motivated to change, making treatment especially difficult. Treatment of dual disorders is hard to accomplish unless sobriety is achieved. Connection to a recovery community is extremely difficult to establish unless one networks and works with existing programs. In spite of these barriers, if one can handle the roller-coaster progress involved, each case of a successfully treated teen/young adult becomes especially gratifying as a life is saved.
The drug epidemic has afflicted young people in America for decades. There is no shortage of ideas on how to solve this problem. From “The War on Drugs” to the “Opioid Epidemic” there have been several campaigns started with the idea of stemming the overwhelming tide of drug abuse. While these approaches are always well intentioned they have done little to decrease drug abuse among young people. There is no magic cure for this problem. Medication may provide temporary relief but it does not change an addict’s thinking. Therapy can be helpful but the discovery of root causes does not motivate a young drug abuser to abstain from mind changing chemicals. Church attendance can lift an alcoholic’s spirits and provide a new perspective but sobriety is certainly not guaranteed. Changes in diet, more exercise, better sleep, and other physical changes are undoubtedly necessary but will not stop a young person from using. A fundamental tenet in any twelve step program is “First Things First.” In order to start the process of recovery an addict must become abstinent. This is the number one priority.
A Program of Attraction
A young addict or alcoholic uses or drinks because the chemical provides a desired effect. By the time drug or alcohol abuse become problematic the abuser knows there is something wrong. One of the primary reasons a person will not stop using is because he or she does not see a better alternative. From an outside perspective this looks insane. To the person who is using, it makes perfect sense. An addict is not concerned with “consequences” until these ramifications stand in the way of being able to get high. Drugs and alcohol affect a person physically, mentally, and spiritually. An addict must have these needs met.Fear is not a good motivator because most young drug abusers are numb to it. Sobriety has to be attractive and fun.
Young addicts and alcoholics wrestle with the temptation to use for a long time after they get sober. They are always aware that “relief” is available from their drug or drink of choice. It is imperative that they have a firm grasp on abstinence before beginning to dig into underlying issues. For young people, this process involves a combination of fun and inspiration. Enthusiastic sobriety opens the door to enjoying a life without drugs and alcohol. It also allows young people to begin coping with difficult issues in a safe and supportive environment.
August and September can be interesting months in the adolescent substance abuse treatment field. Vacations are wrapping up, school is starting, and many families are trying to navigate the stress and anxiety attached to attempts at motivating teenagers. This is the time of year that parents of substance abusing young people pray their children will go back to school and turn over a new leaf. In fact, numerous young people will make empty promises to their parents that real change is on the horizon. “This school year will be different!” they say. When dealing with a child who is abusing drugs and alcohol, parents must understand that the abuser will say almost anything to not have to stop using. Unfortunately, the commitment to academic excellence is the biggest weapon in a teenagers manipulation arsenal. Parents desperately hope their child will go back to school and be “normal.”
The False Security of School
“He/she must really be bothered by seeing everyone go back to school.” This statement is normal for parents in denial. These parents are desperately clinging to the idea that their child places the same value on school. In reality, it is the parents who feel the blow to their self worth. They believe they have failed as parents. They are convinced that somehow they have done something wrong. For a young person in the midst of addiction, education has zero priority. The motivation to learn will come but it will be later in the recovery process. If the first priority is not abstinence the chances of a young drug abuser staying sober are very slim. One of the primary goals of substance abuse recovery is for the young person to get back on track. However, timing is critical.
Don’t Put the Cart Before The Horse
If a young person is suffering from a substance abuse issue, very little will change until he or she is sober. Once the fog of drugs and alcohol has cleared, the addict will start to think about aspects of life that have been compromised by drug use. Once this happens it may still take a significant amount of time to make progress in these areas of life. It is very important for parents to let go of what others may think or how they will be judged. What matters at this point is the young person’s sobriety and the relationship between the parent and child. There will be plenty of time to resolve education issues and become more “mainstream.”
Substance abuse recovery for young people is not the same as it is for adults. A common misconception is that a program designed for adults can be delivered to young people in an effective manner. There are numerous problems with this belief. People will often assume that a young person has the same sense of urgency as someone who has been drinking or using for several years. This rarely happens. There are several reasons why this is the case.The combination of years of abuse, brain development, and life experience create a much different perspective for adults than for adolescents.
The Adolescent Brain
One significant factor in the difference between adults and young people in recovery is brain development. When a young person starts using drugs or drinking alcohol he or she is at a point in life when the brain is going through significant changes. In his book Sacred Connections, Dr. Steven Jaffe gives a great explanation of how the brain is affected in recovery. Dr. Jaffe explains: “The nucleus accumbens is the pleasure and reward system; it is responsible for drug seeking behaviors. The prefrontal cortex helps to regulate impulses and make informed and smart decisions. Unfortunately, this area of the brain does not fully develop until a person’s mid-twenties.” (Jaffe, 72) This clarifies why an adolescent struggles to make better decisions in recovery, even after abstinence. The drug abuser’s brain has been compromised and it takes time to create better decision making skills.
Healing Takes Time
Recovery doesn’t happen quickly. It is a process. In an enthusiastic sobriety program the combination of fun and engaging activities with strong counseling is key. Twelve step recovery involves physical, emotional, and spiritual healing. This has to be attractive to an adolescent so he or she can maintain motivation. Fear will not inspire long term change in a young person. He or she needs a loving, safe, and fun environment along with supportive relationships. As the addict forms a strong foundation in recovery, he or she will practice better ways of thinking as his or brain develops. All adolescents experience periods of emotional instability. This is exacerbated when a young person is using drugs and drinking. It takes an extended period of sobriety for emotional and mental health to internalize.
No one wants to wake up one day and realize their son or daughter has a serious drug and/or alcohol problem. Most parents would rather be thinking about how to help their child navigate through more “normal” adolescent challenges. Unfortunately many families will run into this problem. An issue some parents struggle with is the recognition that priorities will have to temporarily change. The sooner a parent figures this out the smoother the recovery process will be for everyone.
One Size Does Not Fit All
Substance abuse recovery for young people is not “one size fits all.” Problems with drug and alcohol abuse among adolescents and young adults can range from periodic alcohol and marijuana use to severe opiate addiction. Some young people are relatively functional while others have no direction. What all young people have in common is that early sobriety is extremely difficult. The more a young person is able to focus on recovery in the beginning, the better. It is extremely important for parents to recognize that it may be necessary to temporarily shift priorities. The simplest example is with school.
This Is Not Forever
We are all conditioned to believe that if a certain level of education hasn’t been attained by a specified age that somehow the child and the parent have failed. Think about that for a minute. There are many things wrong with that perspective. That is not to say that education isn’t important. Obviously, it is critical to gain a worthwhile education. However, if a young person isn’t functioning emotionally it will be extremely difficult to learn, excel, or care. In fact there are some drug abusers who are able to do well in school primarily to keep people off their back. The point is that while a young person is learning to stay sober, his or her focus will not be on school. Once the newly sober person is stable his or her ability to care about work, school, and other aspects of a healthy life will change. It is vital to trust the recovery process. A couple of points to remember:
- early recovery is difficult for everyone involved
- once an addict is thinking clearly his/her priorities will change
- this is temporary
Patience is difficult but in this case it is vital. Remember that building a strong foundation in early recovery sets the addict up for success in life.
There has been some recent interest in the use of smoking marijuana as a harm-reduction strategy to treat opiate/heroin addicts. To further evaluate this issue, we conducted clinical interviews with 10 opiate/heroin severe substance abuse use disorder patients being treated in an Enthusiastic Sobriety Intensive Outpatient Program.
Ten patients between the ages 14 to 19 years were interviewed; eight males and two females; all met DSM 5 criteria for severe substance use disorder, opiates/heroin. They had been sober between five days to nine months when they relapsed by smoking marijuana. All ten were motivated by the belief that smoking marijuana would help them not to return to opiate use; however, within the range of a few days up to six months, each resumed opiate use.
Patients described the following: “marijuana use was not enough-made me want to use heroin;” “smoking weed make me not care and I went back to opiates;” “the weed made me want more;” “each time I relapsed on weed, I would immediately think heroin is so much better;” “weed just didn’t cut it. I’m smoking weed to get high, but heroin is so much better;” “The weed was just not enough and accelerated my need for a better high.”
All of these patients relapsed by smoking marijuana, which they thought would help them not to return to opiate use. In each case smoking marijuana was not sufficient, and they all returned to heavy opiate/heroin use. Since they all smoked marijuana which contains THC, these case reports are not helpful as to whether just CBD would have a beneficial effect.
In summary, 10 young opiate/heroin severe substance use disorder patients tried to smoke marijuana as a way not to return to opiates/heroin use. In each case this failed.
Steven L Jaffe, MD
Professor Emeritus of Psychiatry, Emory University, Clinical Professor of Psychiatry, Morehouse school of Medicine
Enabling is a word that has been used in drug and alcohol recovery circles for decades. It can be a term that is very misunderstood and misused. No loved one of an addict or alcoholic wants to be thought of as an “enabler.” To enable literally means to make something possible or easy. It can also mean to permit. An enabler is often believed to be complicit in the drug abuser’s self-destruction. The most common forms of enabling include: providing money to an active user, allowing an active addict/alcoholic to remain at home, paying for an addict/alcoholic’s legal costs, and other actions. Sometimes providing help in these ways is not enabling. How can one determine the difference?
Demonstrations of Love
The enabler will say that he or she is “just trying to help” or “what am I supposed to do, let him go broke or die?” It is never a question as to whether or not a parent or significant other loves the addict or alcoholic. The issue is always the demonstration of love. When most people think about “love” they are actually referring to sentiment. Love, as an action, is not always the easiest path to take. Sometimes love is best demonstrated through not accepting behavior that is harmful to one’s self or other people. When an active addict or alcoholic is allowed to avoid consequences of his or her behavior he or she is not being “loved.” This sounds harsh but consider the alternative. Someone actively using is not rational. His or her decisions are not made based on concern for self or others. The addict only wants to be left alone so he or she can continue to use. People are either a means to this end or are in the way. Until he or she is abstinent this way of thinking will not change.
Consider the Motives
There are some simple questions a loved one can ask when confused about whether or not a pattern of enabling is taking place:
- is this going to help my loved one find sobriety?
- am I doing this/providing this help because I feel guilty?
- am I worried about what others will think?
- am I doing this because it helps my loved one or because it will make me feel better?
These are not the only questions to ask but it is a beginning. Not every situation is the same. What one person does may be enabling while someone else does the exact same thing and it is not. There is no exact formula. Always seek the guidance of someone who is objective and has experience in this area. No loved one ever has to face these difficult decisions alone.
Twelve step recovery can be very challenging for young people because so much of it is based on concepts that are usually associated with an adult perspective. A realization of powerlessness, any admission of wrong doing, reliance on a Higher Power, and a willingness to face people who have been hurt is difficult. This is particularly a challenge for adolescents and young adults. Adults in recovery have a difficult time taking responsibility for their actions, much less a young person. In the mind of a young drug and/or alcohol abuser there is nothing wrong with what he/she is doing. In his or her mind if everyone would just back off, there wouldn’t be a problem. This has always been a challenge for young people who need help but is especially difficult today.
Drug and alcohol treatment is not immune to the current climate of identity separation. If you look around, there are 12-Step meetings available to almost every imaginable classification of people. Many of these group distinctions are unnecessary and can water down the message of recovery. It is generally dangerous for a person with drug and alcohol problems to be “terminally unique.” However, young people are at a different stage of development. Not only are they working through a dangerous drug and alcohol problem they are experiencing normal brain development along with hormonal changes. This can be a lot to deal with. These factors don’t excuse poor behavior but must be understood when treating young people. An 18 year old with an opiate or marijuana addiction is not going to experience early recovery the same way a 45 year old alcoholic does. (Yes, I am aware that I wrote marijuana addiction)
Sobriety: The Great Equalizer
Any recovering addict or alcoholic learns the importance of “living life of life’s terms.” The sober man or woman recognizes the value in being a productive member of society. The same is true for a young person. Although some of the definitions may differ, a person in recovery needs to mend broken relationships, become responsible, and learn to adapt to changing circumstances. These characteristics are essential to long term recovery. The twelve steps provide a simple framework to achieve these goals. Change may not happen immediately but with patience and perseverance these turnarounds can be permanent.