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Center for Substance Abuse Treatment. Treatment of Adolescents with Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 32.)

Cover of Treatment of Adolescents with Substance Use Disorders

Treatment of Adolescents with Substance Use Disorders.

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Chapter 4—Twelve-Step-Based Programs

In the United States, many public and private substance use disorder treatment programs, including those for adolescents, subscribe to the 12-Step-based approach organized around the philosophy of Alcoholics Anonymous (AA) (Bukstein, 1994; Institute of Medicine [IOM], 1990). AA is an organization that began as a fellowship devoted to helping those who wish to stop drinking. From its original two members in 1935--Bill W., a stockbroker, and Dr. Bob, a surgeon--it has become an international organization consisting of more than 73,000 groups worldwide, with an estimated membership in the United States and Canada of approximately 800,000 (IOM, 1990). Certainly, any discussion of contemporary treatments for adolescents with substance use disorders must include a review of 12-Step models because of their great influence on substance use disorder treatment.

Interestingly, there is a notable lack of research on 12-Step-based programs, which have for nearly three decades been the most prevalent model of treatment (Bukstein, 1994). Yet family-based models, which are relatively new, have been impressively evaluated with controlled studies (see Chapters 5 and 6). This is partly because most 12-Step-based programs do not have a research tradition due to their emphasis on preserving the anonymity of their members.

Although AA does not view itself as a treatment modality (Laundergan, 1982), it plays a prominent role in the design and implementation of 12-Step-based programs in two important ways: (1) It fosters relationships with the local treatment facilities, and (2) its philosophy, methods, and materials are formally integrated into the treatment activities (Gallant, 1988). Practically speaking, some 12-Step-based treatment programs are headed by private physicians or affiliated with a hospital, whereas others, often led by mental health professionals, are "self-standing." Although generally characterized as aftercare, 12-Step-based programs are sufficient treatment for millions of people, young and old, around the world.

The 12 Steps

The 12 Steps were written in 1938 by the founders of the fledgling AA and originally appeared in what is known to legions of recovering adults as the Big Book (AA, 1976). In AA, sobriety is maintained by carefully applying this 12-Step philosophy and by sharing experiences with others who have suffered similar problems. Many clients who are involved with AA find another AA member who will serve as a sponsor and provide guidance and help in times of crisis when the return to substance use becomes overwhelming. This sharing and group support approach has spawned a number of self-help programs, such as Al-Anon (for families and friends of the alcoholic) and Narcotics Anonymous (NA) (for persons addicted to substances other than or in addition to alcohol). Learning and practicing the 12 Steps, which are listed below, is the main focus of AA and NA. NA programs change some wording in the first and last steps to make them appropriate to users of illicit drugs and other substances; these appear in parentheses.

  1. We admitted we were powerless over alcohol (our addiction)--that our lives had become unmanageable.
  2. We came to believe that a Power greater than ourselves could restore us to sanity.
  3. We made a decision to turn our will and our lives over to the care of God as we understood Him.
  4. We made a searching and fearless moral inventory of ourselves.
  5. We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
  6. We were entirely ready to have God remove all these defects of character.
  7. We humbly asked Him to remove our shortcomings.
  8. We made a list of all persons we had harmed and became willing to make amends to them all.
  9. We made direct amends to such people wherever possible, except when to do so would injure them or others.
  10. We continued to take a personal inventory and when we were wrong promptly admitted it.
  11. We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
  12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics (addicts) and to practice these principles in all our affairs.

Treatment effectiveness is believed to be maximized the more a client is able to personalize the concepts expressed by the steps into her own life.

From AA to the Minnesota Model

Different ways of incorporating the 12 Steps into treatment have evolved over the years. A major adaptation of the model initially developed at Willmar State Hospital in Minnesota has become known as the Minnesota model. By the 1980s, it was the linchpin of almost all programs treating alcoholic and other substance-dependent patients. The goals of the Minnesota model include moving away from the simple custodial care of alcoholics, clarifying the distinction between detoxification and treatment, and identifying a variety of elements of care within one program. The continuum of care components generally includes a diagnostic and referral center, a primary residential rehabilitation program, an extended care program, residential intermediate care (e.g., halfway houses), outpatient care (diagnostic, primary, and extended), aftercare, and a family program.

The Hazelden Foundation further modified this model of care, which preceded enrollment in a primary care program with several days of detoxification in a separate facility. The Minnesota model tried to develop an environment of recovery in a setting removed from daily life, often in the country, for a few months.

The approach that evolved was highly structured and included detoxification, psychological evaluation, general and individualized treatment tracks, group meetings, lectures, and counseling, as well as referral to medical, psychiatric, and social services, as needed. Group counseling was considered the main therapeutic technique. Emphasis was on using older, more advanced residents to share experiences and to pass on knowledge and values to patients. The 12 Steps were carefully studied, and AA meetings were held within the treatment framework. The primary care program was intended to last up to 60 days in a residential setting in the hope that a caring and low-stress environment removed from traditional daily life would facilitate the recovery process.

In the early 1960s, Hazelden developed a 21-day version; insurance companies then set 28 days as a reimbursement guideline in order to ensure sufficient coverage. This abbreviated version viewed intensive treatment as a multidisciplinary endeavor, in which the physician, nurse, psychiatrist, psychologist, counselor, and administrators were involved in a hospital setting. Rehabilitation was provided after intensive treatment by nonmedical staff and coordinated by the counselor. Participation in AA for patients and in Al-Anon for family members got started during treatment and ideally continued for 2 years after treatment. More specifically, treatment components included

  • Strong AA orientation
  • Skilled alcoholism counselors as primary therapists
  • Psychological testing and psychosocial evaluation
  • Medical and psychiatric support for coexisting disorders
  • Therapists trained in systematized methods of treatment including Gestalt, psychodrama, reality therapy, transactional analysis, behavior therapy, activity therapy, and stress management
  • Use of therapeutic milieu and crisis intervention
  • Systems therapy, especially with employers, and later including a family component
  • Family- and peer-oriented aftercare (Stuckey and Harrison, 1982)

For many years, some in the treatment field considered the Minnesota model the only "workable" method of treatment for substance use disorders. Then, as the nation's attention in the 1970s and 1980s focused on the use of illicit drugs (e.g., cocaine), three trends in service delivery occurred. First, treatment programs expanded their curriculum to address substances other than alcohol. Second, new programs were developed that specifically addressed individuals with nonalcohol substance use disorders. Third, both types of programs eventually discovered that alcoholism and substance use disorders overlapped, and thus most programs oriented themselves to the treatment of both.

As the years passed, additional types of treatment approaches emerged, including social model programs and programs based in psychology, such as family-based therapy in its many forms. Parts of the 12-Step-based approach were incorporated into these treatment programs. Since the advent of managed care, outpatient programs of all approaches are becoming the norm. Residential programs within the public or private sector have become less common and often have diminished lengths of stay. Those that remain are often located within institutions, such as correctional institutions or hospital-based psychiatric units.

Incorporating the 12-Step-Based Approach

Although the Big Book contains stories of the drinking experiences and recovery of middle-aged adult alcoholics living in a very different time from today, its principles are relevant to adolescents (Winters and Schiks, 1989). Providers treating adolescents in a 12-Step-based program should bear the following in mind:

  • Substance use disorders are primary, multifaceted illnesses that exist in people of all ages, including adolescents.
  • Persons with substance use disorders are individuals with unique and separate needs who share a common problem and therefore should be treated with respect and dignity.
  • Once substance-abusing and substance-dependent adolescents are given information about their disorder(s) in an understandable way, they are capable of helping others, as long as they receive some guidance.
  • Use of group therapy is well suited to adolescents, who tend to rely heavily on peer examples and approval. Thus, mutual sharing in a peer group setting is vital to the rehabilitation process.
  • The principles of recovery outlined by AA provide effective and proactive tools for continuing one's recovery from drug involvement.
  • Once a person has lost control over his use of substances as an adolescent, returning to responsible and legal use as an adult may require additional help and support.

12-Step Principles in Treatment

Most 12-Step-based programs concentrate on the first five steps during primary treatment, whereas the remaining ones are attended to during aftercare. Below are ways to present the first five steps to adolescents so that their specialized developmental needs can be addressed (Winters and Schiks, 1989).

  • Step 1: We admitted we were powerless over alcohol--that our lives had become unmanageable. With adolescents, the primary goal of this step is to assist them in reviewing their substance use history and to have them associate it with harmful consequences. It helps them understand their need for support in not using.
  • Step 2: We came to believe that a Power greater than ourselves could restore us to sanity. At a practical level, this step can be simplified to "There is hope if you let yourself be helped." A powerful way to convey this message involves allowing new clients to interact with those who have been successful and are leaving the program. The "goodbye" or graduation ritual for successful clients helps to instill hope in others. Providers must help adolescents with coexisting mental disorders or cognitive disabilities to understand that Step 2 refers to obtaining help to stop substance seeking and use and not "curing" their mental disorder. Providers should also spell out that depression or anhedonia after abstinence is common and can get better.
  • Step 3: We made a decision to turn our will and our lives over to the care of God as we understood Him. This step can be simplified as well: "Try making decisions in a different way; take others' suggestions; permit others to help you." Using the phrase "Helping Power" instead of "Higher Power" can benefit some.
  • Step 4: We made a searching and fearless moral inventory of ourselves; Step 5: We admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Steps 4 and 5 provide an opportunity to be accepted by another person in spite of one's past behaviors and to take a "personal inventory" of those past behaviors. These steps enable clients to put some of their past unpleasant substance use experiences behind them.

Some other aspects of the 12-Step model may also have to be modified for adolescents. For example, the tenet that newly abstinent members should have no major life changes for 1 year in order to concentrate solely on their recovery may be difficult for adolescents to internalize. A year has a different meaning in their world, and many changes are an inevitable aspect of adolescence. An advantage of using a 12-Step-based program and having a sponsor is that help is available 24 hours a day, not only when the staff is on duty. It is an empowering idea to know that help is "only a phone call away."

Obviously, an important goal of 12-Step-based programs is to build an affinity between the client and AA meetings. The goal is to teach the young client that continuing participation in these group meetings after treatment is important to his recovery. Young people are increasingly joining AA and NA groups; in some cities, regular AA and NA meetings exist that are attended by teenagers and young adults and that are supervised by an appropriate adult. This continuing support network is believed to be invaluable to the ongoing recovery process.

Individual Treatment Planning

All teenagers in treatment have some problems in common, and these can be addressed in groups. Clearly, group work is a hallmark of 12-Step-based treatment. However, many needs of individuals in this age group are best addressed in one-on-one or other specifically planned interventions in individualized treatment plans. For example, in 12-Step-based programs, such individualized planning often revolves around work on one or more of the steps, and many 12-Step plans address life problems and how the concepts of AA can be used as problem-solving strategies. Also, given that family is a core treatment component, it is common for the client's specialized plan to address family issues such as substance use norms in the family, familial abuse, and sibling relationships.

It is also common for individualized treatment plans to address the teenager's social anxiety. For example, patients with difficulty speaking in a group setting should meet with a counselor and work on strategies to address the source of the problem. The counselor and the client can discuss ways of setting ground rules with peers who use substances when social circumstances arise in the future. Also, some clients will want to discuss how to best develop a future relationship with an appropriate sponsor.

Research Studies

In recent years, there has been modest progress in addressing the question of whether adolescents improve after treatment of substance use disorders (e.g., Catalano et al., 1990-1991; Friedman et al., 1986, 1994; Hoffmann et al., 1987, 1993). It is perhaps ironic that the widely used Minnesota model approach has received relatively minimal research attention. When large-scale studies have been conducted, they have suffered from poor followup contact rates and usually do not include comparison groups. Hazelden's Youth and Family Center in Minnesota conducted a treatment outcome study of 480 clients who completed treatment in the mid-1980s. However, only 53 percent of the sample were contacted at 1 year after treatment. Almost half (46 percent) of those contacted reported no use of alcohol, and over two-thirds (68 percent) indicated no use of other substances during the followup period (Keskinen, 1986).

Harrison and Hoffmann reported outcome results from several residential treatment programs, many of which were based on the Minnesota model (Harrison and Hoffman, 1989). Data from 924 adolescents (49 percent of the eligible followup sample) were collected; 42 percent reported total abstinence during the followup period, and another 23 percent had used substances less than monthly. There are smaller scale evaluations of 12-Step-based programs that have better followup rates (e.g., Alford et al., 1991; Brown et al., 1989; Knapp et al., 1991; Richter et al., 1991); these studies report abstinence rates in the range of about 50 to 60 percent.

In a recent evaluation of a 12-Step-based approach, some of the methodological weaknesses of previous studies were addressed, namely, a high contact rate at followup was achieved and meaningful comparison groups were included (residential vs. outpatient, and no treatment vs. treatment) (Winters et al., in press). Six- and 12-month substance use outcomes were measured among 245 drug clinic-referred adolescents, 179 of whom received complete or incomplete treatment and 66 of whom were deemed to need treatment but did not receive any. The intent-to-treat adolescents showed significant reductions in substance use frequency when preintake levels were compared with followup levels. Fifty-three percent of them reported either abstinence or minor lapses (substance use only once or twice) during the 6 months following treatment, while 44 percent reported this status for the full year following treatment. Absolute and relative outcome measures indicated that completing treatment was associated with far superior outcomes when compared with those who did not complete treatment or received no treatment at all. The percentage of those completing treatment who reported either abstinence or minor relapses for the 12 months following treatment was 53 percent, compared with 15 percent and 27 percent for those who did not complete treatment or who did not receive treatment, respectively. There were no outcome differences between residential and outpatient groups, yet females tended to report better outcomes compared with males. Among the intent-to-treat subjects who relapsed, alcohol was the most commonly used substance during the followup period, despite marijuana being the preferred substance at intake. Until more rigorous research designs are applied, the most conclusive statements that can be made about the effectiveness of the 12-Step-based approach for adolescents is that many youths are improved after receiving this form of care. Although some preliminary data indicate that the 12-Step-based method yields outcomes that are superior to no treatment at all, there is a great need for controlled studies in this field.

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