Model for Treatment of Adolescents
Adolescents pose unique issues:
• Biological developing in the body, brain and hormonal systems continue well into the mid and late 20s, so when treating an adolescent, many bodily systems are still developing.
• Adolescents are fairly concrete thinkers, and eventually move into being more abstract thinkers in the late teens and early 20s.
• Over time they improve in their ability to link causes and consequences, particularly stringing events over time with outcome. However, in early to late teenage years, causative links are
difficult for them to find.
• There is an inevitable movement in most cultures, especially for adolescent boys, to separate from a family-based identity seeking instead the development of peer- and individual-based identities.
• There is an increased focus on how one is perceived by peers as well as increased rates of sensation-seeking/trying new things.
• The development of impulse control and coping skills is often delayed in many adolescents, appearing in one’s early or mid 20s.
• In many situations, there are concerns about avoiding emotional or physical violence. Many children who have lived on the streets are victims of physical and sexual abuse and violence.
Therefore, when working with adolescents, the following principles apply:
• Examples need to be altered to relevant situations and triggers.
• Consequences need to be altered to things of concern to them.
• For those with a history of substance use and abuse, they do not recognize their substance use
as a problem and are mandated into treatment by the judicial system, their families, etc.
• All materials need to be converted from abstract to concrete concepts.
• Co-morbid problems (mental, trauma, legal) are to be considered the norm not the exception and often pre-date substance abuse patterns.
• Treatment has to take into account multiple systems (family, educational, welfare, criminal justice).
Model of Treatment
There are evidence-based practices (EBPs) with good indicators for success.
• Dialectical Behavior Therapy (DBT). DBT is grounded on CBT principles augments with acceptance-based interventions, validation strategies, and dialectical strategies as a means to balance acceptance and change. Treatment is broken down into various stages of change with specific targets/goals for each stage. Issues such as post-traumatic stress disorder (PTSD) are specially addressed in later stages of change. Our model combines a DBT and Seeking Safety (see below) to dealing with trauma.
• Attachment, Regulation (Self), and Competency (ARC). ARC provides a theoretical framework, core principles of intervention and a guiding structure for caregivers working with adolescents and children, while recognizing that a one-size model does not fit all. Attachment addresses attunement of one’s life through rituals and routines. Self-regulation provides skills in affect identification, affect modulation, and affect expression. Competency addresses executive functioning, self-development skills, and trauma experience integration. ARC is specifically designed to address trauma in children.
• 12 Step approaches. The 12 Steps of Alcoholics Anonymous can be utilized for substance abusing and non-substance abusing population. The core principles of 12 Steps are: surrender and acceptance of the issues, making amends for prior behaviors and finding a meaningful way to carry on with one’s life. This framework forms the underlying principles for all adolescent treatment.
• Cognitive Behavioral Therapy (CBT). Behavioral approaches focus on the underlying cognitive processes, beliefs, and environmental cues associated with the teen’s use of substances and teaching them coping skills to help them remain drug-free. The goal of our behavioral approach is to teach the adolescent to “unlearn” their destructive behaviors, seeking pro-social ways to cope with their lives. In particular, given behavior is mediated by thoughts and beliefs, so the focus is on altering thinking as a way to change behavior. We emphasize aggression replacement training, reasoning, change thinking, interpersonal social problem solving, multi-systemic therapy, multidimensional family counseling, adolescent community reinforcement, and assertive continuing care.
Other behavioral approaches focus on the development of coping skills, introduced and modeled by staff. Such skills training include substance refusal skills, resisting peer pressure to use substances, communication skills (non-verbal communication, assertiveness training, negotiation and conflict resolution skills, anger management skills), problem-solving skills, relaxation training, social network development, and leisure-time management. New behaviors are tried out in low-risk situations (during group counseling role play sessions, individually with their counselor) and eventually applied in more difficult, “real life” situations. Homework assignments are used to try out new behaviors or for collecting problem situations to discuss during counseling. Staff and more senior patients provide positive reinforcement for the use of new, healthier behaviors.
• Seeking Safety. The Seeking Safety model is an integral approach founded on Cognitive Behavioral Therapy. Modules from Seeking Safety have been abstracted and revised to fit the culture of Turkey.
• Behavioral Contracting. Behavioral contracting is used to set behaviors to be changed. Weekly/daily incremental goals are mutually agreed upon. As each goal is reached, the adolescent is highly praised and reinforced through privileging. Behaviors are explicitly defined on the contract with criteria and time limitations noted.
• Family-based approaches. These approaches acknowledge the critical influence of the adolescent’s family system in the development and maintenance of problems. Our family program is multi-dimensional and progressive, depending on the stage of development, familial relationships, severity of the illness and impaired relationships. Our approach includes observing the family’s interactional patterns, identifying problems in interactions, education of the family concerning their adolescents’ problems and how the family is involved, and steps the family can take on their own to address the adolescent’s issues.
• Young Adult Philosophy/Positive Peer Culture. Positive Peer Cultures (PPC) emphasize demanding excellence in actions versus obedience to rules, although the application and adherence to rules and regulations are an important part of the maturation process for adolescent males. PPC stress values versus rules, where caring and compassion for one another is fashionable. The first step in building a PPC is to establish a problem-solving list, behaviors and emotions which the adolescent faces that needs to be addressed.
Key elements for defining positive youth development include promoting bonding, fostering resilience, promoting social, emotional, cognitive, behavioral and moral competence, and fostering self-determination. We also seek to foster spirituality, self-efficacy, clear and positive identity, and hope for the future. Finally, we seek to provide recognition for positive behavior and opportunities for social, healthy involvement with peers.
The goal is to assist the adolescent to develop a sense of competence, being able to do something well, usefulness, having something to contribute to society and his family, a sense of belonging, being part of a community and having relationships with caring adults, and a sense of power, having control over his future, separate from the impact of drugs.