Engaging Adolescents in Treatment

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1 Egagig Adolescets i Treatmet Assistig adolescets to reflect o their curret situatio ad experieces ad helpig them to evisio a positive future may promote motivatio to chage, especially amog those who have bee there, doe that ad are willig to look ahead. Jaet C. Titus, Susa H. Godley, ad Michelle K. White A Post-Treatmet Examiatio of Adolescets Reasos for Startig, Quittig, ad Cotiuig the Use of Drugs ad Alcohol To successfully idetify ad treat adolescets with traumatic stress ad substace abuse, cliicias must cotiually explore better ways to ecourage their participatio i treatmet. This is particularly importat i metal health ad substace abuse service systems, where these tees preset a uique set of challeges. Adolescets with both traumatic stress ad substace abuse ofte have complex histories ad umerous additioal problems that make them particularly difficult to treat. Although empirically-based treatmet itervetios offer adolescets a good chace of success i overcomig a variety of psychological problems, may youth fail to obtai treatmet, ad those who eter treatmet ofte termiate prematurely. Cliicias who work with adolescets ecouter a series of challeges whe tryig to egage youth who have histories of traumatic stress ad substace abuse. Most adolescets do ot eter treatmet volutarily ad are ofte apprehesive about the process. Furthermore, substace abusig adolescets, much like their adult couterparts, ofte have a hard time makig positive chages i their use patters. To provide effective services, these challeges ad barriers must be addressed. Idetifyig ad Ecouragig Youth to Seek Help Tees ted ot to seek out professioal help for a variety of reasos. They may ot believe they eed help. They ofte are ot aware of the rage of services available. They may be cocered about the stigma of obtaiig metal health services or hesitat to seek out a adult for assistace. Researchers ad cliicias have developed a variety of ways to overcome these iitial hurdles. The Natioal Child Traumatic Stress Network

2 Offer multiple types of assistace Tees are far more likely to seek assistace for problems with employmet, relatioships, ad family tha they are for metal health or emotioal issues like posttraumatic stress or substace abuse. Agecies that ca act as resource ceters ad offer a variety of services that might be sought by tees themselves are more likely to be i a positio to help a adolescet with multiple problems, icludig those related to trauma ad/or substace abuse. Idetify youth i schools Schools are a key access poit for early idetificatio of at-risk youth. Outreach ca be coducted i school usig peer etworks, stadardized screeig programs, or a combiatio of the two. Peer etworks utilize studet leaders who have bee traied to provide assistace to at-risk tees. By makig use of i-school studet support resources, cliicias are more likely to idetify youth who would otherwise ot have approached a adult for treatmet. Programs that employ peer support etworks should provide close adult supervisio to peer supporters ad have couselors readily available to provide assistace to at-risk youth idetified by their peer supporters. At-risk studets ca also be idetified through screeigs ad evaluatios coducted i school or after-school settigs. Cliicias admiisterig aual or semiaual metal health or substace abuse screeigs at a school ca help Breda s Story* Breda, a 16-year-old mother of a 10-mothold boy, was madated to treatmet after a marijuaa-related arrest. Bor ito a chaotic family, Breda has lived at various times with her mother, her father, ad other family members; she ow speds most of her time with the father of her so at his parets home. Breda bega drikig ad smokig marijuaa whe she was 10. At age 12, she bega sellig marijuaa ad other drugs ad became ivolved i a loosely orgaized gag. She has atteded school oly sporadically sice she was 14 years old. Illegal substaces were commo i the eviromet where Breda was raised. Both of Breda s parets have bee itermittet users of heroi ad other drugs, ad her father spet a sigificat amout of time i jail durig Breda s childhood. Breda was sexually assaulted by a adult fried of her father s at age ie. Breda prided herself o ever usig heroi, ad o just usig marijuaa ad alcohol. Eve the occasioal use of cocaie was of very little cocer either to her or to most of the importat figures i her persoal life. Breda is a watchful, cautious, strog-willed, ad outwardly cofidet girl. She speaks quietly about feelig old, feelig resposible for her youger sibligs ad her so, ad about feelig disillusioed with the world, particularly with her father. Attedig school, followig the rules, ad meetig the expectatios that are typical for girls her age hold little meaig for her, ad she has few dreams for her future. She is highly suspicious of other people s itetios, ad experieces a sese of profoud iterpersoal distace. It is ot likely that Breda would have etered treatmet without havig bee madated by the court. * Breda is a composite represetatio based o real teeage cliets strugglig with traumatic stress ad substace abuse. 2 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

3 idetify youth who would ot have sought treatmet or otherwise bee idetified, thus facilitatig youths egagemet i treatmet or services. May schools scree their adolescet studets for substace abuse problems usig the CRAFFT questioaire, a brief (six-item) screeig test that ca idetify adolescets who are egaged i risky behaviors with alcohol or drugs. 1 3 Programs that employ the Cogitive- Behavioral Itervetio for Trauma i Schools (CBITS) have also successfully screeed large umbers of studets for traumatic stress withi high school populatios. (For more iformatio o screeig tools, see Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems.) Gettig Adolescets i the Door No-show rates for iitial sessios at substace abuse cliics are reported at about 50%. 4 Factors associated with missed appoitmets iclude active substace abuse, youg age, ad atisocial behavior. Listed below are some of the ways cliicias ca icrease the likelihood that a adolescet will atted the first sessio ad cotiue comig thereafter: Make remider calls. Call the adolescet s home prior to the appoitmet ad speak with both the youth ad a paret. Tell them that you look forward to meetig them. Discuss the importace of arrivig at the sessios o time; metio a couple of success stories with previous cliets, ad ask about ay obstacles to attedace they aticipate Be especially welcomig at the first sessio. Praise the tee ad family for just makig it to the first sessio Be culturally aware ad sesitive. Whe egagig youths ad especially their caregivers from diverse backgrouds, it is essetial to be aware of cultural values ad expectatios that guide social iteractio, metal health/substace abuse treatmet, ad saliet themes i their commuities. Establishig the trust of youths ad families from diverse backgrouds is a importat factor i determiig whether they will cotiue to show up for appoitmet, ad the quality of the iitial iteractio will greatly ifluece this decisio. If ay staff members are uaware of the cultural backgrouds of the youths ad families they are likely to assist, make sure they receive traiig i cultural competece; this will greatly cotribute to successful treatmet egagemet ad delivery (For more o this topic, see Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems.) Reach out to the family. Make a itese outreach effort startig with the very first sessio. Obtai several ways to get i touch with the youth ad the family ad The Natioal Child Traumatic Stress Network

4 get cotact iformatio for those ivolved i their care. Make follow-up phoe calls, lettig them kow that you care ad that you wat to cotiue to see them. This is particularly importat for adolescets who are madated for treatmet Egagig Homeless Youth Drug use by homeless youth is reported to be double that of youth i school. 5 Furthermore, homeless adolescets who abuse substaces egage i more high-risk behaviors, are more resistat to treatmet, ad have higher rates of psychopathology ad family problems tha substace-usig adolescets who are ot homeless. While egagig this overlooked populatio i treatmet is particularly importat, it is also a especially challegig edeavor. Homeless youth are very ulikely to self-refer to treatmet ad, as they are frequetly ot i touch with caregivers, are rarely referred by motivated family members who may have otherwise iitiated treatmet. Although shelters are the primary itervetio for these adolescets, may are ot equipped to provide treatmet for the multiple areas of eed ad diverse co-occurrig coditios characterizig this populatio. Strategies to egage substace-abusig homeless adolescets ad their families i treatmet iclude: 6 Stay at their level whe makig the first cotact. Showig the adolescet that you uderstad his or her laguage ad culture will facilitate egagemet. Let him or her kow that you are kowledgeable about the issues faced by may homeless adolescets, such as a history of abuse Preset treatmet optios i a o-threateig, appealig maer. Avoid askig persoal questios, ad stress that tees similar to him or her have participated i ad beefited from the program Avoid blamig. Reframe curret situatios (e.g., drug behavior, livig i a shelter) i terms of relatioal factors rather tha persoal failure Covey hope ad empowermet. Commuicate that chage is possible ad that the tee will have cotrol over his or her participatio i treatmet Respect his or her cocers, such as those surroudig cofidetiality or egagig primary caregivers, ad beig ope to egotiatio Addressig Practical Barriers to Care May adolescets ecouter real barriers to accessig treatmet, ad it is sometimes ecessary to provide guidace ad assistace to help parets, caregivers, ad adolescets overcome them. 4 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

5 Schedulig Both parets ad adolescets may have difficulty with schedulig appoitmets. If a family is workig with other treatmet team members, try to coordiate with these members to schedule as may appoitmets as possible o the same day, so that the family has to make oly oe trip to your locatio. Discuss the possibility of holdig sessios before or after usual busiess hours to eable families to schedule appoitmets aroud work ad school commitmets. Trasportatio Discuss with the youth ad family ay potetial obstacles they might have to gettig to appoitmets regularly. Wheever possible, offer to provide bus or trasit passes if your ceter is ear public trasportatio. Address child care limitatios Families may have youg childre to care for ad may ot be able to afford child care durig family sessios or paret sessios. If your agecy has access to voluteers, ask them to assist with child care while parets are i sessio. Address caregivers treatmet issues Caregivers may eed referrals for treatmet themselves. Providig idepedet referrals for caregiver treatmet may help to alleviate stress o a family. Gettig Families Ivolved Adolescets whose caregivers are ivolved ad egaged i treatmet are more likely to have better outcomes tha those whose caregivers do ot believe that treatmet will help ad/or who are uwillig to work with treatmet providers. 7 Specific strategies for ivolvig families i treatmet iclude: Foster family motivatio. Determie what chages each family member would most like to see ad icorporate those chages ito treatmet goals to icrease the family s motivatio ad egagemet Validate parets. Validate parets past ad ogoig efforts to help their adolescet Ackowledge paretal stress. Ackowledge parets stress ad sese of burde (both as parets ad as idividuals) Be a ally for the paret. I additio to tryig to maage their tee s emotioal ad behavioral problems, parets are ofte overwhelmed by difficulties i their ow lives. Be sure to provide active support ad guidace The Natioal Child Traumatic Stress Network 5

6 Provide educatio about the ature of metal health problems. Families may prefer to see their adolescet s symptoms solely as a medical ad/or behavioral problem, ad ot as a metal health problem. I the case of substace abuse, for example, families may believe that oce the adolescet is sober, all emotioal ad/or behavioral problems will disappear. Psychoeducatio regardig the ature of substace abuse ad emotioal problems may help family members better uderstad their adolescet s issues Address complex family dyamics. Adolescets ofte come to treatmet with complex family backgrouds. It is importat to idetify the family members ad/or caretakers who have legal custody ad practical ifluece over treatmet-related decisios. It is also importat to idetify others who are most likely to be ivolved i a adolescet s care day to day, icludig close frieds ad metors who might support the adolescet s successful egagemet i treatmet. Be particularly sesitive to situatios i which a adolescet does ot live with a biological paret Buildig Alliaces As with ay treatmet, it is importat that youth ad caregivers feel that their cliicia is a ally. This icludes havig a set of commo goals. The etire family must believe that their work with the cliicia ad participatio i treatmet will lead to improvemet i issues that are importat to them. Establish rapport, set clear boudaries, ad allow for autoomy. May adolescets do ot respod to a itervetio that they perceive as beig imposed upo them, whether by a cliicia, parets, or other authority figures. Regardless of the specific treatmet approach, it is essetial to get to kow the adolescet i the begiig of treatmet ad develop a solid workig relatioship. It is also essetial to outlie a framework for the therapeutic relatioship that establishes clear boudaries but also allows the adolescet to make autoomous decisios Fid out what the adolescet wats to talk about. Although adolescets may be reluctat to disclose details about their risky behavior, there are ways to ecourage meaigful coversatios that will lead to ope discussio about what is goig o i their lives. These strategies iclude: P P P Showig geuie iterest i ad respect for his or her uique iterests, cocers, ad worldview Demostratig uderstadig of his or her culture Offerig guidace that addresses the adolescet s life problems as he or she perceives them 6 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

7 Iformig youth about ormal behavior Teeagers beefit from cotrastig their behavior with that of the average perso their age. A 13-year-old who believes that everyoe gets druk sometimes may be surprised to lear, for example, that the majority of 8th-graders have ever bee druk. 8 It is crucial to provide tees with iformatio that clarifies the differece betwee recreatioal use ad problematic use (icludig abuse or depedece). Usig appropriate assessmet tools Admiisterig assessmet istrumets that are t face-to-face teds to ecourage greater disclosure. Adolescets ted to provide more iformatio o topics such as substace abuse ad suicidal ideatio whe they are t talkig to a cliicia. For example, cliicias ca use the Adolescet Questioaire (Adquest), a 80-item self-report measure that icludes questios about health, sexuality, safety, substace abuse, ad frieds, desiged to ope up may areas of iterest ad egage the adolescet i coversatios ivolvig these topics. 9 (See Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems for more o this ad other assessmet resources.) Discussig the limits of cofidetiality To build trust with a adolescet, discuss the limits of cofidetiality at the start of treatmet ad pla with the adolescet specifically how iformatio will be commuicated to parets ad other authority figures. Stick to your agreemet! There is o surer way to lose the trust of a adolescet tha by sharig iformatio without the adolescet s awareess. Reassure the adolescet that if you must disclose iformatio (e.g., if someoe s life is i dager), you will make every effort to tell him/her before you do it. Employig Motivatioal Iterviewig Motivatioal iterviewig (MI) has bee show to be effective at reducig alcohol ad substace use i adolescets with a iitial low motivatio to chage. 10 Although it is ot possible to address the full scope of MI i this abbreviated format, some of the mai priciples iclude: Takig a empathetic, ojudgmetal stace ad listeig reflectively. This ivolves attemptig to uderstad teeagers perspectives ad helpig them feel uderstood, so that they ca be more ope ad hoest with others Idetifyig how the adolescets curret behavior may affect their goals. This ivolves workig with adolescets to idetify persoally meaigful goals, ad helpig them to evaluate whether what they are doig ow will iterfere with where they wat to be i the future The Natioal Child Traumatic Stress Network 7

8 Rollig with resistace. Rather tha arguig with tees whe they hit a roadblock, help them develop their ow solutios to the problems that they have idetified Supportig self-efficacy for chage. The belief that chage is possible is a importat motivator for successful chage. Help adolescets to be hopeful ad cofidet about their ability to impact their ow future i a positive way Leavig the door ope Whe adolescets wat to termiate treatmet, make sure they kow that they ca come back at ay time. Experieced treatmet providers kow that ofte it takes awhile for a adolescet to start comig i regularly. Ehacig Commuity Awareess Commuity members ofte iteract with tees, but they ofte do ot have the traiig to idetify ad uderstad youth at risk. To improve commuity awareess, substace abuse professioals ad metal health providers should make every effort to provide commuity groups with iformatio about the symptoms associated with substace abuse ad traumatic stress, as well as iformatio about factors that ca icrease or mitigate the risk of these disorders. Armig the commuity with this kowledge will be useful i idetifyig ad treatig youth i eed, as well as i prevetig future difficulties. It is also critical to provide commuity member with liks to help. This icludes iformatio regardig hotlies to call whe a perso suspects that a child or adolescet is beig abused, cotacts for guidace durig a crisis, ad referrals for meetig additioal youth ad family eeds. 8 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

9 Refereces 1. Kight, J. R., Shrier, L. A., Braveder, T. D., Farrell, M., Vader Bilt, J., ad Shaffer, H. J. (1999). A ew brief scree for adolescet substace abuse. Arch Pediatr Adolesc Med, 153(6), Kight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., ad Chag, G. (2002). Validity of the CRAFFT substace abuse screeig test amog adolescet cliic patiets. Arch Pediatr Adolesc Med, 156(6), Jull, A. (2003). The CRAFFT test was accurate for screeig for substace abuse amog adolescet cliic patiets. Evid Based Nurs, 6(1), Lerma, P., ad Pottick, K. (1995). The parets perspective: Deliquecy, aggressio, ad metal health. New York, NY: Gordo ad Breach Sciece Publishers. 5. Forst, M., ad Crim, D. (1994). A substace use profile of deliquet ad homeless youths. Joural of Drug Educatio, 24, Slesick, N., Meyers, R. J., Meade, M., ad Segelke, D. H. (2000). Bleak ad hopeless o more. Egagemet of reluctat substace-abusig ruaway youth ad their families. J Subst Abuse Treat, 19(3), Dakof, G., Tejeda, M., ad Liddle, H. (2001). Predictors of egagemet i adolescet drug abuse treatmet. Joural of the America Academy of Child ad Adolescet Psychiatry, 40, Johsto, L. D., O Malley, P. M., Bachma, J. G., ad Schuleberg, J. E. (2007). Moitorig the Future: Natioal results o adolescet drug use: Overview of key fidigs, Bethesda, MD: Natioal Istitute o Drug Abuse. Retrieved April 16, 2008 from org/pubs/moographs/overview2006.pdf. 9. Peake, K., Epstei, I., ad Medeiros, D., Eds. (2005). Cliical ad research uses of a adolescet metal health itake questioaire: What kids eed to talk about. Bighamto, NY: The Haworth Press, Ic. 10. Miller, W., ad Rollick, S. (2002). Motivatioal iterviewig: Preparig people for chage. 2d ed. New York, NY: Guilford Press. This project was fuded by the Substace Abuse ad Metal Health Services Admiistratio (SAMHSA), U.S. Departmet of Health ad Huma Services (HHS). The views, policies, ad opiios expressed are those of the authors ad do ot ecessarily reflect those of SAMHSA or HHS. The Natioal Child Traumatic Stress Network 9

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