Revolutionizing Recovery: Proactive Strategies for Youth Substance Use Disorder Treatment

In over 40 years in the field of Chemical Dependency treatment, we have never encountered a client who expressed relief at having waited so long to seek help. Instead, the opposite sentiment is far more common. Clients often delay action until the consequences become unavoidable, such as facing divorce when a process server arrives or encountering legal troubles with a second DUI before finally resolving to seek treatment. Similarly, concerns about family dynamics might linger without resolution until a client is confronted with the possibility of not being allowed to see their grandchildren.

To be sure, there is a definite connection between the 26-year-old diagnosed with an Opioid Use Disorder (OUD) and the 16-year-old version of himself who knew there was something special about the pills he was given when he had his wisdom teeth taken out, but that connection is neither linear nor inevitable. Substance Use Disorders (SUDs) in adolescents occur for different reasons than they do in adults. They develop differently, and they demand different interventions and treatment. Adolescents who use substances are doing so when their brains are still growing and developing. This phenomenon can be further exacerbated by the presence of learning disabilities, trauma, and Mental Health Disorders (MHD) like AD/HD. They are also more likely to engage in activities where using and drinking is the activity rather than a component of the social event. Finally, mixing different substances to achieve a sufficient or particular high can be more common. To reduce the chances of adolescents with active SUDs becoming adults with active SUDs, we believe we need to redouble our treatment efforts in a purposeful, systematic, and thorough way.

In its earliest incarnation, our program treated only adolescents. We created what we believe to have been the first Intensive Outpatient Program (IOP) for adolescents. As part of the IOP, counselors conducted individual, group, and family sessions. The families were also part of specially designed education sessions. Once families had a better understanding of addiction and what recovery for the family really entailed, they often, then, joined our Family Support Group. We traveled around the country to present lectures and to consult with other providers to assist them in establishing their own programs to work with this—still, we believe—underserved population. During this time of collaboration and research, we developed a list of what we feel are the necessary fundamentals that clinicians treating adolescents must employ if they wish to maximize the effectiveness of the treatment they provide. For this article, we have included summarized versions of 12 of these fundamentals (there will be a total of 14 in the third edition of the book “Effective Outpatient Treatment for Adolescents”), and we hope you find them helpful.

1. The Substance Use Disorder is Primary:

First and foremost, chemical dependency treatment for adolescents must address their SUDs as the primary presenting illness (this, of course, assumes the adolescent is physically and mentally suitable for treatment). We understand that adolescents may have co-occurring or co-morbid issues, and it is not always clear which issue is contributing to or exacerbating which, but viewing an SUD as a related consequence rather than a separate factor is a mistake (Gust D., Smith T., 1994). Not only does this approach ensure that clinicians will properly evaluate the severity of the clients’ potential SUD, but it is the only way to eliminate the variable of intoxication- or withdrawal-induced symptoms from further mental or physical health assessments.

2.   Screening and Referral for Co-Occurring Disorders:

Screening for the client’s Substance Use Disorder (SUD) is our initial task. Once this is complete, we proceed with screening for past and current Mental Health Disorders (MHD). This phase is conducted as the counselor navigates through the intervention phase of treatment, particularly while clients discuss their emotional lives leading up to initial substance use and describe how substances have altered, managed, or augmented their emotional experiences. The biopsychosocial assessment will delve deeper into the relationship between emotions and substances. It is crucial to note, however, that diagnoses for MHD should be made only by licensed professionals. There are numerous reasons to begin this screening as early as possible, but a few of the most critical include:

• A. The inextricable link between emotions and the interplay of MHD and SUDs—specifically, the attempt to control these emotions—underscores the necessity of addressing both to foster stable recovery.
• B. This approach offers a dual benefit: it validates the clients’ experiences and struggles, and subtly prepares them for the broader scope of comprehensive treatment.
• C. For practical purposes, it’s essential to assemble the necessary members of the clients’ care teams as early as possible.

3.   Screening and Referral for Past, Present, and Recurrent Trauma:

In this section, we recommend using a broad definition of ‘trauma’ and concurrently screening for traumatic events, Early Life Stress (ELS), and Adverse Childhood Experiences (ACE). We opt to separate these screenings from Mental Health Disorders (MHDs) for several reasons, the most crucial being that trauma, ELS, and ACE are highly predictive of future SUDs and MHDs. Failing to do so could result in overlooking the root causes of a client’s difficulties by focusing too heavily on the symptoms (Jones et al., 2019). Furthermore, discussing such events can be an effective way to build essential rapport with clients by demonstrating a desire to understand the factors that led them to view substances as useful, preferable, or necessary. Clients may have suspected that certain events in their lives were traumatic, stressful, or adverse but never received validation for these thoughts. Often, they are dismissively told to “just stop using.” This lack of acknowledgment can foster negative self-perceptions and obscure the link between their traumatic experiences and substance use.

4.   Structured Process for Assessment, Intervention, and Fostering Behavioral Change:

Once a client’s counselor has completed the initial assessment for trauma and co-occurring disorders, it is appropriate to begin a schedule of regular individual sessions. However, we urge practitioners to proceed more cautiously than they might in an Intensive Outpatient Program (IOP) or inpatient setting. Our experience suggests that while a cohesive group can motivate a reluctant or anxious client in these settings, individual clients may show more hesitancy in one-on-one counseling sessions. It is common for issues raised during the biopsychosocial assessment to bring past feelings and experiences to the surface, making the early stages of treatment potentially more challenging and unpredictable than the initial intake period. Crisis may seem like the norm for some clients, but a structured approach to counseling can provide a repeatable framework for interventions that ensures:

1. Continuous assessment and integration of findings.
2. Ongoing discovery by clients of how their SUD has impacted their lives, enhancing their understanding of their reactions and behaviors.
3. The ability of counselors and clinical teams to remain focused and effective, even if a client’s life circumstances remain unstable.

This structured approach should not prevent attention to urgent issues or crises but should rather provide a context that helps manage and utilize such challenges effectively during ongoing treatment.

5.   Family Involvement:

Family involvement is very often critical to adolescents’ success in treatment. Fortunately, many families who seek help for their children are highly motivated and willing to engage in all aspects of the counseling process. However, this is not universally the case. The term “families” encompasses not only biological relatives but also mixed, multi-generational, foster, and community groups. These are the people who recognize the issues, identify the need for treatment, and support the client’s desire for change by providing support and accountability.

Once clients are stable and actively participating in counseling, it’s time to deepen family involvement. Initial interactions with clients’ families typically involve taking comprehensive family histories of addiction and/or Mental Health Disorders (MHD). This is followed by discussions about past recovery attempts from Substance Use Disorders (SUDs), which lead to examinations of family dynamics and communication styles that could either support or hinder recovery efforts, particularly focusing on enabling behaviors and codependency.

These discussions lay the groundwork for bringing families and clients together to focus on how SUDs have affected each person individually and the family system as a whole. It’s crucial to stay focused during these meetings, especially in families where dysfunction and confrontational behavior are common, to avoid getting mired in personal grievances. These initial meetings are not for judging past actions but for sharing and learning from each other’s experiences.

In later sessions, there will be opportunities for families and clients to discuss their needs and hopes for the future. It’s important to note that while outpatient treatment has limited hours, engaged families can significantly extend the benefits of this treatment by acting as a support system beyond the clinical setting. Conversely, families who do not commit to the recovery process can inadvertently obstruct it, making their involvement a critical factor in the treatment’s success.

6.   Intervention as Process Rather than Event:

At the start of treatment, it is quite common for clients to view their Substance Use Disorders (SUDs) superficially: “I like to get high,” or, “I’m stressed, and alcohol calms me down.” Previously, we labeled such clients as “in denial.” Now, we categorize them as being in the “Pre-contemplation” stage, but the meanings are similar: these clients do not believe there is a problem with their substance use. As such, they may trivialize upcoming interventions: “I won’t buy as much,” or, “I’ll only use on weekends.” While this may be wishful thinking, it’s understandable; after all, if the change seems easy, the problem can’t be that severe. However, over time, clients may realize that their SUD is more complex than they initially thought.

Counselors will engage with clients in individual and (likely) group sessions. If treatment proceeds appropriately, they will also conduct joint sessions with clients’ families and liaise with external members of the treatment teams. These interactions are opportunities to uncover, define, and organize areas of the clients’ and/or families’ lives that need change or focus. You have likely encountered many families who delayed seeking treatment until it was unavoidable. Consequently, they are likely facing problems in behavior and communication that accompany those specifically related to SUDs. Counselors aim to direct clients to discuss aspects of their lives they wish to change. This doesn’t mean the counselor agrees with the clients’ (or families’) choices or preferences, but it is crucial to start by empowering clients, impressing upon them that they are not passive observers. Setting goals and involving clients in developing activities, practices, and feedback to meet these goals not only focuses their efforts but also provides a framework through which counselors can help contextualize future efforts and objectives. This approach is akin to asking, “How does this or that behavior move you closer to or further from your goal?” Over time, clients will better understand their SUD objectively. What seemed initially to be the most urgent need might become secondary to more central, unmet needs. In some cases, ongoing intervention may become necessary for families: if they find the problem to be more serious or complex than initially thought—than hoped—their approach to treatment and ongoing recovery will need to adapt accordingly.

7.   Confidentiality is not Secret Keeping:

Fundamental 7 is crucial to the ongoing intervention process, focusing on ensuring confidentiality without confusing it with secret keeping. This gives counselors an opportunity to enhance their clients’ autonomy in life. While certain disclosures must be shared with families, counselors have some discretion—varying by jurisdiction—over what must be reported versus what may be reported. Often, clients, whether adolescents, young adults, or adults, are not very forthcoming in the early stages of sobriety. A common reason is their desire to protect their “pathological relationship to substances” (Gust D., Smith, T., 1994). Despite knowing deep down that their substance use is problematic, adolescents may fear that being too open will lead to reprimands, ultimatums, and punishments. They may also come from families where open communication is discouraged or absent. Claudia Black’s three rules in such families are: “Don’t talk, don’t trust, don’t feel,” (Black, pg. 24). In this environment, an adolescent might wonder, “What’s the point of telling my family? They’re just going to get mad, tell me I was wrong to start, and demand I stop.”

Addressing this fear—of judgment, disappointment, or retribution—is essential. Clients need assurances that they can speak openly and honestly with their families in a trusting and respectful setting. These initial and follow-up sessions provide significant opportunities for clients to grow more comfortable discussing both past experiences and current insights with their families. Over time, as clients achieve sobriety, they become more willing and able to discuss past drug and alcohol use and associated emotions. Realizing they can share their experiences without being judged allows them to view their past actions more objectively and say, “That’s what I did, but that’s not who I am.”

This shift is pivotal for clients’ engagement in recovery activities like 12-Step programs, recovery meet-ups, and focusing on diet and exercise. Rather than mourning what they must eliminate from their lives—drugs, alcohol, friends in addiction—they start to appreciate what recovery adds to their lives: new friendships, improved physical and emotional health, and hope for the future. An effective treatment program facilitates these discussions, advocating for clients while helping them stay accountable.

8.   Community Enabling:

In this section, we define enabling as any behavior or inaction that fosters an environment conducive to ongoing substance use by shielding adolescents from the reasonable consequences of their actions. Put another way, if individuals or social/legal systems can influence adolescents to decrease or stop their substance use and choose not to, these entities are effectively enabling the continuation of substance use. We have observed scenarios where various individuals, including school counselors, law enforcement officers, coaches, and family friends, failed to act upon recognizing adolescent substance use due to a fundamental misunderstanding of its implications. To address this issue, our program has long engaged in providing outreach and education to schools and community support groups. We aim to ensure that more people and organizations understand that early substance use is not just a phase or a rite of passage for a significant portion of the population. Through both reactive and proactive community outreach, our program strives to foster a more informed response to adolescent substance use.

9.   Serving Suitable Clients:

When members of the family or community observe that an adolescent is using substances, the first step is to schedule an assessment. Individuals who have good chances of benefiting from outpatient treatment should meet certain initial criteria, including: an ability to remain substance free outside of a 24-hour facility, a willingness—even grudging—to participate in individual counseling sessions, and a home environment that is safe and supportive. As their time in treatment progresses, counselors will want to look for certain changes, including: a pattern of engaging in “change” talk when discussing ongoing recovery or other positive alterations to their lives, increasing insight into the benefits of returning personal agency, being supportive of other clients and their respective recoveries, and a willingness to have their families involved in their treatment.

10.   Regular and Random Urine Screens:

All the while, regular and random urine screens for substances is of the utmost importance. First, insight and openness are very unlikely to improve if clients continue to use substances, as protecting the relationship to substances requires the perpetuation of dishonesty, obfuscation, and only superficial disclosures. Secondly, urine screens give counselors, clients, and families at least one empirical data point in what can be, at least at the beginning, an endeavor fraught with uncertainty. For counselors, it demonstrates required compliance and willingness and also makes it easier to begin to trust the clients’ disclosures and emotional reactions and responses. For families, it presents them with one solid, unequivocal measurement of progress and change. And for clients, they may recognize two benefits fairly quickly: it can feel validating to be believed and to see some trust return, and negative screens can provide them with proof that they have the ability to stay sober and, ultimately, engage in recovery.

11.   Staying Current:

Effective programs stay current. This means continuing education (in-person whenever possible) for clinical and support staff on applicable and practical topics, maintaining active referral and contract relationships with mental health and medical professionals, integrating client perspectives and feedback into intake and program processes, and reviewing group and individual session materials annually, to name just a few. As we are all aware, our field does not stand still, and the need for effective treatment has arguably never been greater. Learning new approaches and techniques is not just important to be sure we deliver the most appropriate interventions with the highest probability of success, but this practice also guards against counselor frustration and burnout.

12.   A Multidisciplinary Approach:

The term “Minnesota Model” describes an approach developed in the late 1940s and early 1950s that has become foundational to modern treatment methodologies in the country. However, not all programs strictly adhere to this model. Most counselors, therapists, and programs recognize Substance Use Disorders (SUDs) as diseases and inform clients about the risk of developing multiple SUDs with different substances (Anderson, 1981). Nevertheless, there are challenges within the Multidisciplinary model, particularly in terms of treatment teams. While counselors form the core of the clinical team, optimal recovery preparation requires the inclusion of physicians, psychologists, psychiatrists, and therapists. We have seen clients whose recoveries were impeded because their treatment focused solely on their SUD without addressing other life aspects, underscoring the importance of a holistic approach to recovery.

Stress is one of the most prevalent symptoms of any SUD. The constant preoccupation with obtaining and hiding substances can be overwhelming, especially during adolescence—a period already fraught with stress. This relentless stress can push aside critical issues like depression, anxiety, trauma, academic struggles, and dysfunctional relationships. In early sobriety, as the obsession with substances wanes, these secondary concerns become more prominent and, if unaddressed, can trigger a relapse. Early intervention and treatment are crucial, as adolescents can quickly escalate from initial use to addiction, sometimes resulting in a prolonged struggle with SUD or even premature death.

The final element of the Multidisciplinary approach focuses on peer support. While the significance of support groups like AA, LifeRing, or Celebrate Recovery is frequently emphasized to adults, such recommendations are less common for adolescents, despite their acute sensitivity to peer influence. If there are few adolescent-specific support meetings available, the role of aftercare groups becomes even more critical. As highlighted earlier, successful recovery is not just hoped for but expected in our approach.

References

• Anderson, D. J. (1981). Perspectives on Treatment: The Minnesota Experience. Hazelden Foundation.
• Black, C. (2020). It Will Never Happen to Me: Growing Up with Addiction as Youngsters, Adolescents, and Adults. Central Recovery Press, LLC.
• Gust, D., & Smith, T. (1994). Effective Outpatient Treatment for Adolescents (1st ed.). New Directions Program Corp.; (2006) (2nd ed.). New Directions Program Corp.
• Jones, C. M., Merrick, M. T., & Houry, D. E. (2020). Identifying and Preventing Adverse Childhood Experiences: Implications for Clinical Practice. Journal of the American Medical Association, 323(1), 25–26. https://doi.org/10.1001/jama.2019.18499

Philip Hodson

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Philip Hodson, CADC II, ICADC is an Addictions and Recovery Counselor (CADC-II, ICADC), working with young-adult and adult males at New Directions Program in Fair Oaks, CA. He has been in the Chemical Dependency Treatment field since 2013. During this time, in addition to his Outpatient practice, Phil has facilitated groups and managed caseloads at both the IOP and Inpatient levels of care. For several years Phil specialized in facilitating lecture groups on the Neurobiology of Addiction.

Phil grew up in Columbia, SC, and he holds bachelors degrees in Economics and French from Hampden-Sydney College in Virginia.

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David Gust

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David Gust is a graduate of the esteemed Hazelden Foundation Counselor Training Program and has been in the field since 1977. He founded New Directions Program in 1981. Currently, he maintains an active caseload as a counselor and, as Co-Founder of Recovery Treatment Consulting (recoverytreatmentconsulting.com), works with individual counselors and programs. In years past, David traveled the country, helping design and develop IOP programs for adolescents.

David co-authored “Effective Outpatient Treatment for Adolescents” and “How to Help Your Child Become Drug-Free,” both which are available at davidgust.net.

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