Assessing Teens Part 2
Elizabeth Escobar Highlights Key Treatment Considerations for Those Working with Adolescent Clients
Assessing teens for an appropriate level of care, as well as addressing treatment issues once admitted, is both a science and an art. In this article we will look at the science behind diagnosis and level of care assessment as well as interaction between clinician and patient. This therapeutic relationship, when undertaken correctly, is a work of art.
When assessing teens for a Substance Use Disorder (SUD), we find it important to use the DSM 5 criteria. It is a surprise to many that the criterion for a SUD diagnosis does NOT assess how much and how often a substance is being used. The diagnosis focuses on the effect the substance has on the individual’s life. Once this diagnosis has been made using the DSM V criteria a level of care assessment needs to be completed. Which substance(s), how often they are being used, how much is being used and date of last use will play a large role in determining which level of care is most appropriate for the teen.
The American Society of Addiction Medicine has created a multi-dimensional assessment that helps guide clinicians to make the appropriate treatment program recommendation. The dimensions are as follows and can be found at asam.org:
Dimension 1 – Acute Intoxication and/or Withdrawal Potential. This allows the therapist and client to explore both past and current experiences with substance use and withdrawal symptoms.
Dimension 2 – Bio-medical Conditions and Complications. It is imperative that a client’s health history and physical condition be discussed for purposes of differential diagnosis as well as a safe/medically managed detox.
Dimension 3 – Emotional, Behavioural, or Cognitive Conditions and Complications. Large portions of substance users also meet criteria for a co-occurring disorder, (i.e. anxiety and mood disorders). Dual Diagnosis is common within this population. Assessing the individual’s thoughts, emotions and mental health issues is critical when determining the appropriateness of treatment.
Dimension 4 – Readiness to Change. Exploring a client’s willingness and interest in change can be assessed using DiClemente and Prochaska’s Stage of Change model. In our experience, it is important to note that individuals who begin treatment in the pre-contemplation stage (denial) CAN successfully complete a program; intrinsic motivation is not a necessary component upon admission to treatment.
Dimension 5 – Relapse, Continued Use, or Continued Problem Potential. Assessing the individual’s relationship with substances and previous relapse is vital. This can be assessed by discussing prior treatment admissions, lengths of sobriety and triggers that have precipitated relapse.
Dimension 6 – Recovery/Living Environment. It is essential to explore the individual’s current living situation (i.e. location, individuals present in the home, availability of substances). Evaluating whether the environment is conducive to recovery may impact the level of care the individual is referred to.
Upon treatment admission, it is crucial to help both teens and parents understand that confidentiality is of utmost importance. When working with teens, keep in mind that they have a tendency to not fully trust adults. While we explain the “breaking confidentially” rules, (in the event of suicide or homicide ideations as well as suspected abuse and neglect) we help teens AND their parents/guardians understand the importance of how we manage this issue. Most adults understand their child’s need for confidentiality in order to move forward. On the occasion that the therapist feels it necessary to communicate specific information to the parents, we often ask teens what they prefer: for the teen to tell their parents or for us to explain it and then they can decide if they want to be present. Teens are often affected by their intense emotions and treatment allows them to process these feelings in a safe environment, often for the first time in their lives. Issues such as deep feelings that may not have been safe to share previously, memories that may be keeping the child “stuck”, or “coming clean” with risky behaviors are important to discuss because breaking secrets is often the key to healthier communication in the family.
It is important for the clinician to remember that a teen does not need to be “motivated” for treatment. Often teens that come in angry, withdrawn or sullen, will do well once in treatment. And, contrary to popular belief, it has been our experience that some client’s who come in “highly motivated” are more likely to leave treatment early or relapse the day they discharge! It is important to remember that when working with teens, the ability to connect early on is crucial. Active listening and validating a teen’s feelings is the best way to build rapport. This can be a delicate balance for the clinician as we do not want to collude with client’s’ distorted thinking, however, letting clients know that you understand how they are feeling will often result in a healthy therapeutic alliance. The concept of “meet them where they are at and take them where they need to be” is a safe clinical approach.
Beyond the therapist/client relationship, it has been our experience as clinicians that the peer group takes on a more significant function earlier in the admissions process in adolescent facilities. For example, on adult units patients are often more defended or guarded and are experiencing more severe physical symptoms, therefore having the tendency to isolate for a longer period of time. Teens, on the other hand, have a natural desire to want to be accepted by their peers and in turn, connect to other patients earlier in treatment. Adolescents often respond well to their peers and a therapist should not hesitate to utilize this valuable connection. Teens who are doing well in treatment are often chosen to be “peer buddies” for the newly admitted patients.
Some teens will present with a dose of bravado and can be more emotionally volatile than adults. Using foul language, refusing to engage in treatment, acting out (side talking in group, unwillingness to talk at all, being sexually provocative) are all tactics teens may use. It is important for a clinician to develop a thick skin and to fight the desire to control behavior but rather interpret it. Suggestions to deal with acting out behavior are to co-opt the Peer Buddy or other peers in treatment, tell the adolescent client that they can take a walk with you or another staff in order to calm themselves, or giving them reminders such as, “I will be back in 10 minutes-play this tape all the way through and then we can come up with solutions.”
On the occasion that a teen enters treatment and has withdrawn, these “peer buddies” can connect with the reluctant client and foster a healthy, sober relationship. In some treatment programs the counsellor and the client’s “peer buddy” offers support while clients “call off using friends.” This is an important and necessary component of treatment. It is imperative that clinicians understand the magnitude of this step. The social bonds that teens create are their lifelines. Simply expecting the teen to cut off their using friends is unrealistic and therapists need to be sensitive to this. Peer Groups are powerful and important for teens’ psychological development. It is a natural time for parental influence to decrease and peer influence to increase. The goal is to help teens understand that a negative peer group may have influenced their decision to start using mind altering chemicals and therefore a positive peer influence will help them decide to stay clean and sober. A Peer Buddy is adept at supporting this difficult task. Clients will see their peer as someone who has been through it, therefore trusting their understanding of the situation.
When working with teens it is important to bear in mind that they are not “little adults”. Teens simply do not have the capacity to make decisions in the same way adults do. Helping teens develop this important skill by role playing and using the Socratic Method of thinking will allow the client to learn to “play the tape all the way through”. We, in essence, lead them to the inevitable conclusion to not use. Encouraging clients to approach recovery “one day at a time” is a concept that teens can appreciate, as futuristic thinking is often difficult for them at this stage of cognitive development.
Drama Therapy is a very effective tool when working with teens. In one session, the treatment team decided it was important for a 17-year-old client to watch an enactment of his own funeral. This client was heavily involved with a local gang and it was powerful for him to see this played out. Peers gave him feedback about the “what if’s” had he continued to use and identify as a gang member. Having a trained/certified drama therapist on staff is helpful.
The most important aspect of working with teens is including the family in treatment. Our general approach is that anyone who lives in the home who is 12 years and older should be included in the family education and family therapy. Adults may have a spouse/partner or occasionally, their parents, involved in their treatment, but with teens, it is non-negotiable. In the next issue we will discuss the role the teen’s family plays in their treatment and how each member who lives in the house and/or has a great influence in the teen’s life will also need to consider a Recovery Program. Addiction is a Family Disease and helping the family come to terms with this fact will help lessen the chance for relapse.
In conclusion, working with teen clients presents its own challenges and requires creativity that is different from working with adults. With a skilled clinician, the utilisation of “peer buddies”, role-plays and drama therapy, learning how to make healthy decisions and fully encompassing the family, adolescent clients will increase their chances of growing and maturing in a healthy way.