FAMILY THERAPY CONCEPTS IN THE TREATMENT OF ADOLESCENTS WITH COOCCURRING AND SUBSTANCE ABUSE DISORDE

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FAMILY THERAPY CONCEPTS IN THE TREATMENT OF
ADOLESCENTS WITH CO-OCCURRING AND SUBSTANCE
ABUSE DISORDERSDwight McCall, Ph.D.,
L.P.C.Child Adolescent Outpatient Services
ManagerRegion Ten CSBCharlottesville,
VAdwightm_at_regionten.org
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• AGENDA
• ASSESSMENT
• SA
• MH
• ADOLESCENT BRAIN DEVELOPMENT
• INTERVENTIONS
• TYPES OF FAMILY-BASED TX
• STEREOTYPICAL STAGES OF TX
• GENERIC INTERVENTIONS PER STAGE
• SPECIAL TOPICS
• GENDER-SPECIFIC TX
• PEERS
• SIBS
• COURT

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• ASSESSMENT
• Substance use - Cclassification schema
• DSM-IV concerns about use with adolescents
• Nowinski five stages
• Recent brain-based studies abuse vs.
  dependence/risk of dependences

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• ASSESSMENT
• Substance use classification schema
• Stages of abuse dependency (Nowinski, 1990)
• Experimental - Mind-/mood-altering effects
  secondary to adventure of use itself
• Social Primary motivation is social acceptance
  and/or disinhibition
• Instrumental Substances intentionally used to
  manipulate feelings or behavior two types --gt
• Hedonistic pleasure-seeking
• Compensatory coping tool
• Habitual initial loss of control life becoming
  centered around obtaining using tolerance
  emerges
• Compulsive complete loss of control

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• ASSESSMENT
• Substance use classification schema
• Recent, brain-based studies
• Three key indicators of risk of dependence
• Early use/rapid decline
• Family history (SA MH at least 2 generations
  back)
• Loss of control (often limited data in
  adolescents)

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• ASSESSMENT
• Substance use classification schema
• Recent, brain-based studies
• Hypothesized status directs goals of treatment,
  including, family therapy
• At risk --gt emphasize abstinence primary focus
  on reduction in use
• Not at-risk --gt harm reduction goal --gt
• Monitor use, but primary focus on other issues
• If substance use impairs ability to work on other
  issues, bring focus back to use and explore need
  for reduction/abstinence

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• ASSESSMENT
• Substance use - Parental substance use
• Sign of genetic risk of dependence in adolescent
• Intervene directly only if parent(s)' use can be
  tied to treatment goals and their ability to
  provide adequate parenting for adolescent

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• ASSESSMENT
• Mental Health
• Why are you asking about MH if client referred
  for SA?
• Self-medication Evaluate, but question of
  direction of causality
• Potential interference of substances with MH
  dx/tx

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• ASSESSMENT
• Mental Health (continued)
• Assessment
• Standard DSM criteria for MH disorders - Most
  common disorders? ADD/ADHD, mood d/o, O. D. D.,
  others?
• Previous dx/tx
• Family hx
• Trauma history
• Open door expect to get limited information
  early on
• De-stigmatize

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• ASSESSMENT
• Implications for treatment
• Need for psychiatric eval/treatment for
  adolescent
• Impact on client's ability to utilize therapeutic
  interventions
• MH issues in parents --gt Ability of parent to
  provide structure necessary for stablization and
  behavior change

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• ADOLESCENT BRAIN DEVELOPMENT
• Marc Fishman, M. D.,Johns Hopkins
• Actual number of brain cells can increase
  (proliferation) or decrease (pruning)
• Number of cells proliferates during prenatal
  period
• Second wave of proliferation occurs between ages
  of 6 12
• Pruning occurs from 11 to 25 girls begin around
  12 boys begin around 12.5
• Changes not complete till about 25much older
  than previously thought

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• ADOLESCENT BRAIN DEVELOPMENT
• Maturation of the brain occurs back-to-front,
  from simple to complex
• Cerebellum
• Nucelus acumbens
• Amygdala
• Prefrontal cortex

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• ADOLESCENT BRAIN DEVELOPMENT
• Cerebellum center of coordination of physical
  activity and senses
• Adolescents prefer physical activities and
  sensation-seeking (drive fast, sports more than
  school, playing video games, etc.)
• Adolescents engage in risky, impulsive behaviors,
  especially when in a group
• Research also shows that serotonin and dopamine
  shoot up when in a group, e.g., hanging with
  friends is a neurochemical high

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• ADOLESCENT BRAIN DEVELOPMENT
• Nucleus accumbens center of motivation
• External/internal - Until brain development
  progresses, motivation tends to be external more
  than internal
• External motivators can be peers /or adults
• Adolescents are more susceptible to large doses
  of external rewards (e.g., drugs)
• Reward anticipation - Compared to adults,
  adolescents have lower ability to anticipate
  rewards in the future ? will throw away large
  rewards in future for small reward today

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• ADOLESCENT BRAIN DEVELOPMENT
• Amygdala center of emotions
• Immature amygdala results in adolescents
  misinterpreting emotional signals
• They occasionally over-read over-react (with
  anger or depression) to situations because their
  brains have misinterpreted what other people are
  doing/saying
• They may also be limited in the ability to
  recognize emotions in themselves (introspect)
  and/or to put emotions into words (articulation)
  - Both of these functions contribute to greater
  regulation of experience and expression of emotion

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• ADOLESCENT BRAIN DEVELOPMENT
• Prefrontal cortex center of judgement/
  decision-making
• Planning, setting priorities, controlling
  impulses, incorporating consequences into
  decisions, transferring learning from one
  situation to the next
• Until this area develops (last), adolescents have
  poor judgement decision-making as compared to
  adults
• Includes comparatively limited consideration of
  negative consequences of their behavior

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• ADOLESCENT BRAIN DEVELOPMENT
• Implications for adolescent substance abuse
• Lowered sensitivity to intoxication ? they can
  use more without getting high BUT higher
  levels of use create greater motor impairment
  (e.g., driving)
• Fewer internal inhibitions against risky behavior
  such as substance use (even worse if ADD/ADHD)
• Poorer judgement and memory disruption ? rewards
  for use outweigh negative effects

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• ADOLESCENT BRAIN DEVELOPMENT
• Whats a Parent (or therapist!) to Do?
• Educate (briefly) about risks and consequences
• Dont be afraid to be the external motivator,
  when necessary. Support the adolescents move,
  over time, toward internal motivation
• Elicit their goals then, if relevant, raise
  doubts/create ambivalence about effectiveness of
  their strategy decisional balance
• Meet resistance with reflection or curiosity more
  than confrontation (roll with the resistance)

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• Family Interventions
• Types of family-based interventions
• Individual family therapy and Multi-Family
  Group
• As part of multi-systemic approach
• One-person family therapy (OPFT)

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• Family Interventions
• Stereotypical stages of therapy/family therapy
  with this population
• Engagement
• Stabilization
• Facilitating change
• Aftercare planning

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• Generic Family Interventions Engagement
• Engage via goal-setting
• What do they want better or different?
• Meeting expectations of outside agencies, such as
  PO
• Clarify expectations, esp. re abstinence vs.
  limited use
• Tie all interventions to their goals
• Engage via joining
• Determine what they want and communicate that you
  hear it and will help them get it
• Priority joining family member who has maximum
  energy for change (usually not the kid!)

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• Generic Family Interventions Engagement
• Engage via education
• SA
• Genetic basis of dependence
• Triggers
• Boredom, peers, school failure, MH sx
• Parents role vs. kids role in changing
• MH
• Biological bases for mental disorders and
  potential role of medications
• Adolescent brain development ? need for external
  (parent, PO) limits

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• Generic Family Interventions Engagement
• Engagement when motivation low and/or no current
  problem
• Explore expectations of external players (court,
  school, etc.)
• MI-like exploration of future if negative
  behavior unchanged
• Predict relapse how handle?

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• Generic Family Interventions Stabilization
• Goal
• Provide level of external structure needed for
  stabilization and adolescent skills development
• Adjusted for level of SA/MH severity, brain
  development stage
• Methods
• Help parents provide positive and negative
  consequences for behavior
• Help parents engage external structure (PO,
  school) in manner which does not undermine
  parental authority or responsibility
• 12-step support
• Minimal utility for adolescents, especially at
  this stage
• Very useful for parents

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• Model-Based Family Interventions
• Facilitating Change
• Goals Long-standing family tx models
• Strategic ? change interactional sequences which
  include problem behavior and ineffective parental
  responses
• Structural ? change ineffective familial
  structures, most commonly, parents not being in
  charge

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• Model-Based Family Interventions
• Facilitating Change
• Methods Structural Strategic FT
• Map the family
• Check for multi-generational boundary violations
  around the chief complaint (structural family
  therapy)
• Identify sequence(s) which include(s) the chief
  complaint (strategic family therapy)

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• Model-Based Family Interventions Facilitating
  Change
• Methods Structural Strategic FT
• Change the family's structure or behavior
  sequence to eliminate the place/role of the
  symptom(s)
• Structural - Change the structure of the family
• Join with the power
• Direct in-session and/or homework tasks which
  operationalize the new structure
• Strategic - Change the sequence by...
• Change behaviors...or...changing meanings of
  behavior as means to open new options
• Use in-session or homework tasks

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• Model-Based Family Interventions Facilitating
  Change
• Goals Evidence-Based Models
• Multi-Systemic Therapy (MST) ? identify and
  address all factors, including family functioning
  which (a) support the problem and/or (b) can be
  engaged to change the problem
• Functional Family Therapy (FFT)
  ?engagement/motivation, behavior change,
  generalization (applying change to other problem
  areas)

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• Model-Based Family Interventions Facilitating
  Change
• Goals - Evidence-Based Models (cont'd)
• Multi-Dimensional Family Therapy (MDFT) ?identify
  problems in adolescent development which connect
  to substance abuse and behavior problems,
  including risk and protective factors
• Contingency Management - Reinforce positive
  behaviors and implementing consequences for
  negative behaviors

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• Generic Family Interventions Facilitating Change
• MH-specific issues
• Parental supervision of med compliance
• Provision of safety physical and emotional
  around trauma
• Sleep hygiene
• Others???

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• Family Interventions
• Aftercare Planning
• Assumptions
• Systems are naturally self-healing --gt if
  re-aligned to normal functioning,they will
  generally solve future problems on their own
  (generalization)
• BUT! They may need to come back some time...
• Neurochemical and social bases for SA MH
  relapses
• Family dynamics --gt problems emerge around new
  developmental or idiosyncratic issues

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• Generic Family Interventions Aftercare Planning
• Goal
• Achieve and maintain desired level of functioning
  (abstinence/harm reduction other behavioral
  goals)
• Plan for dealing with set-backs
• Methods
• Relapse prediction/innoculation
• Decreased frequency of sessions
• 12-step and other supports

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• Special Topics
• Gender-Specific Issues (Source Monica
  Cates-Rosko, L.P.C.)
• Females heal in community relationship with
  others and relationship with self
• Relationship with therapist
• Relationship with group
• Relationship with family permission to be who
  you are in the context of your family
• Normalize adolescents feelings (or lack thereof)
  and expression of feelings
• Help client and family identify what she doesnt
  experience as safe (may be unexpected)

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• Special Topics
• Gender-Specific Issues (continued)
• Teach safety skills (example when angry, leave
  the room until you can handle it)
• Trauma - At least 25 have been molested
• Trauma begets violence and hostility or extreme
  passivity
• Therapeutic goal create a safe place
• Treatment tends to focus more on self-discovery
  and choices than on SA per se

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• Special Topics
• Peers
• No hard fast rule about extent to which peer
  system must be changed (cf. adults)
• Initial goal parental awareness of who peers
  are and what theyre doing
• Tie limits to adolescents inability to manage
  peer relationships at this point (not choosing
  my friends)
• Identify limits of parental powercontrol what
  you canand support implementation of those
  limits

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• Special Topics
• Role of siblings
• Families where focus on older problem child (a)
  distracts from IP, or (b) makes IP target of
  displacement
• Interventions
• SFT ? generational boundaries
• Experiential ? sculpting (Wegscheider roles)
• Interaction with court system
• Helping parents engage the system without
  abdicating responsibility
• Clinician as clinician , not secondary PO
  (boundaries)