Treatment of Dually Diagnosed Adolescents: The Individual Therapeutic Alliance Within a Day Treatment Model

This chapter describes a day treatment model for adolescent drug abusers with a comorbid psychiatric disorder, with emphasis on those aspects of the individual counselor's relationship with the adolescent client specific to this program. Clinical techniques are described as they relate to the common treatment goals of motivating adolescent clients toward abstinence from alcohol and other drugs (AOD) and other self-destructive behaviors, preventing relapse, assisting adolescent clients in learning to recognize and tolerate strong affective states, and developing alternate coping mechanisms to drug abuse as a means of regulating these affective states. The importance of a sophisticated integration of psychodynamic clinical techniques with traditional chemical addiction or 12-step recovery model techniques is discussed as central to an effective working individual alliance with dually diagnosed adolescent clients within both group and individual treatments. Finally, a specific analysis of the interpersonal dynamics of the client-counselor relationship and the individual characteristics of the counselor is presented and discussed as central to the effectiveness of this model.

While biological and social factors play an important role in the etiology and maintenance of addictive behavior, it is the various psychological vulnerabilities that underlie the abuse of mood-altering drugs in adolescent clients that are central to the goals, structure, and function of the Center for Child and Adolescent Treatment Services (CCATS) Model. The uses of social reinforcement as a primary treatment technique, the referral of adolescent clients to 12-step meetings like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and the use of traditional, educationally oriented counseling techniques and teaching of "the disease model" of alcoholism and addiction are discussed in depth in this chapter.

It is the authors' hypothesis that most of the adolescent clients treated within the CCATS Model have underlying deficits that have roots in the common experience of trauma, including pervasive sexual and physical abuse, loss, and inadequate parenting, in addition to the complicating factors of learning difficulties, parental alcoholism and drug abuse, and longstanding behavioral and emotional difficulties. These combined predisposing or premorbid psychological vulnerabilities can be characterized as consisting of various clusters of characterological deficits, deficits in self-structure, and patterns of maladaptive coping that have been longstanding and in fact may have been learned from earliest childhood as attempts by the child to adapt to a chaotic and unsafe emotional environment (Wood 1988). In this light, drug abuse is viewed as an effort to self-medicate (Khantzian et al. 1990).

CCATS is a service of the Danbury Hospital, a teaching facility located in Danbury, CT. Adolescents 12 to 18 years old and their families make up the population being served. Adolescent clients presenting for treatment come from inpatient hospitalization; referrals from schools, court, and outpatient agencies; and family referrals. The CCATS Model serves both adolescent clients with a primary psychiatric disorder and those who are dually diagnosed—those with a coexisting psychiatric disorder and drug abuse and/or addiction disorder as diagnosed using DSM-IV criteria. The program description that follows focuses on the dual-diagnosis treatment track of the program, although many components of the program structure are the same for both clinical populations. Adolescent clients attend treatment for 4 hours a day, 5 days a week initially, and then transition to a 3-day-per-week program as they prepare for discharge and aftercare. Average length of stay is 6 to 8 weeks, with variations in length of stay determined by severity of symptom profile, psychosocial stressors, and global assessment of functioning upon intake and admission and during course of treatment. The involvement of family members or a foster parent or legal guardian is mandatory, as this involvement is viewed as essential to successful treatment outcome.

Adolescent clients must be willing to accept the structural requirements of the program, which include daily urine drug screening, random testing for blood alcohol level through the use of a breathalyzer, attendance at a minimum of three 12-step meetings (AA, NA, or Cocaine Anonymous [CA]) in the community outside of program time, and agreement to the disclosure of any relapse or serious violation of program rules or self-destructive behavior to their participating family members or legal guardians. Adolescent clients are also required to be enrolled in an educational program, usually a modified day at their own junior or senior high school, that could include tutorial or graduation equivalency diploma (GED) preparation.

Given this extensive level of behavioral expectations and limits around the amount of continued drug use while in treatment, candidates for this treatment approach must have at minimum a modest amount of motivation to establish abstinence. Motivation for sobriety is first assessed at the time of the initial evaluation and then on an ongoing basis throughout the course of treatment. Motivation may come from internal or external sources, but it is viewed as deriving from the adolescent client's distress. This distress may take the form of disappointment in self, depression, guilt, or fear of consequences (i.e., legal, familial, biological). Evidence of the nature and extent of this distress is actively solicited during the intake/assessment interview. Clinical staff make a conscious effort to maintain or heighten this distress in treatment, eventually working with the adolescent client to help shift his or her distress from being external to internal and from being punishment oriented toward being health oriented. Adolescent clients with a strong history of conduct-disordered behavior must be able to manage these behaviors in a less restrictive environment, as the CCATS Model uses only behavioral reinforcement techniques and "time out" in a nonrestricted environment for infractions of rules.

Drug abuse and chemical addiction are viewed as primary disorders and are addressed as such. This clinical emphasis on the primacy of drug abuse disorders is based on the observation that adolescents actively engaged in regular use of mood-altering drugs have significant difficulty addressing any other treatment goal and in fact most often exhibit disinhibited expression of aggressive impulses and acting-out behaviors. Thus, the hierarchy of treatment goals, although individualized and specific to each adolescent, begins with the motivation of the adolescent toward abstinence from alcohol and other drugs and the decrease and ultimately the cessation of any use of mood-altering drugs. The secondary treatment goals are individualized but can be categorized as specific to the dominant psychiatric illness that is comorbid to drug abuse. For example, an adolescent client who presents with major depression disorder will have as treatment goals reduction and cessation of acute depressive symptoms. An adolescent client displaying conduct disorder with drug abuse will be encouraged to adopt treatment goals of cessation of the conduct-disordered behavior and development of alternative coping mechanisms to acting-out behaviors. In addition, the program focuses on the successful management of prominent self-destructive behaviors. Examples of typical behaviors observed in this population might be stealing, lying, school truancy, oppositional and defiant behaviors, sexual promiscuity, unnecessary physical risk taking, and social involvement with peers who are involved in drug use and antisocial behavior. The treatment philosophy emphasizes a reasoned, democratic, educational focus on the impact of self-defeating or self-destructive behaviors on the adolescent client's own personal goals and experience of conflict within interpersonal relationships and the experience of intrapsychic distress and anxiety.

Given the strong influence of the family's overall level of functioning, treatment goals always incorporate some measurable behavioral improvement in family functioning, from a decrease or cessation of intense conflict within the family to the referral of parents or siblings to their own treatment outside the program structure for psychiatric or drug abuse treatment, which is viewed as detrimental to the safety and psychological well-being of the adolescent client.

Finally, additional treatment goals in this approach are determined by the adolescent clients themselves. Examples of self-selected treatment goals include pursuing educational and vocational interests, exploring transferential phenomena, examining psychological conflicts, pursuing spirituality in a 12-step program or elsewhere, and exploring new or previous recreational pursuits or interests.

Lifestyle change is central to accomplishing most of the significant treatment goals within this model, most importantly the acceptance and adoption of an abstinent or "recovering" lifestyle through the positive influence of the prosocial culture of the treatment milieu and referral to meetings such as AA and NA.

Within the Dynamic Integrated Treatment Model, the theoretical rationale is that drug abuse is an overdetermined phenomenon maintained as a behavior (despite significant negative consequences) because of its adaptive function as self-medicating underlying depression and overwhelming affective states (Bukstein et al. 1992; Fairbairn 1981; Khantzian 1978). Because of this assumption of the primary etiology of the behavior of drug abuse, all other aspects of the model are informed by the adolescent client's specific core issues related to loss, trauma, psychiatric illness, and related underlying vulnerabilities.

Within this framework, resistance to the establishment and maintenance of abstinence is seen as normal, predictable, and key to the establishment of long-term behavioral change. The mechanism of action within this model includes the provision of ego-supportive psychotherapy, as well as dynamically informed interpretation of an adolescent client's resistance and the underlying dynamics that block that client's ability to accept strategic or more behaviorally oriented counseling help. Furthermore, the mechanism of action is the use of the therapeutic alliance with the treatment staff to help adolescent clients consciously acknowledge, understand, and integrate aspects of their resistance to change and growth through the establishment of abstinence. Facilitating this process are various methods of behavioral and cognitive structure that are described in detail in this chapter.

The adolescent client is viewed as the primary agent of change; however, the use of group affiliation with both the treatment milieu and 12-step fellowships outside of treatment serves as powerful motivation for adolescent clients, as do the individual relationships and alliances with the counselors within the program. Although these factors provide influence and structure, the emphasis is placed on the adolescent client's decision to absorb and use the structure, treatment, advice, and reinforcing aspects of these varied parts of the treatment. Any emphasis the adolescent client may make in attributing the causative factors of change as being outside of his or her self is carefully examined and interpreted. Counselors foster an environment where the adolescent client gains self-esteem through gradual acknowledgment of self-efficacy and internal locus of control in choosing to use the social and therapeutic support systems provided through the treatment center.

The language used by treatment staff, the behavioral expectations the staff have for adolescent clients, and the means through which behavioral limits are set and consequences given for the violation of behavioral limits make clear the underlying assumption of the treatment culture. Within this model, adolescent clients are viewed as responsible for their own behavior and ultimately responsible for the behavioral changes necessary for establishing and maintaining an abstinent or "recovery" lifestyle. While initial behavior change is acknowledged as difficult and painful at times by the staff's empathic feedback and explorations of ambivalence, the adolescent client is still viewed to be self-regulating and able to tolerate the difficulty inherent in change through use of appropriate social support and diversion techniques. The adolescent client is also encouraged to begin to recognize his or her abdication of responsibility outside of his or her self as central to the current difficulties.

Central to the understanding of this treatment approach is a description of the conceptualization of drug abuse and dependence and their relationship to coexisting psychiatric disorders. Within this approach, drug use by adolescents is viewed as a social norm, whereas drug abuse and addiction are viewed as symptomatic of psychological vulnerabilities and an attempt to self-medicate affective states of sadness, anger, anxiety, frustration, and depressive symptoms. It is held within this model that depressive disorders and psychiatric symptoms predate the onset of drug abuse disorders in adolescents (Christie et al. 1988; Deykin et al. 1987; Newcombe et al. 1986).

The model of drug abuse and addiction as a biopsychosocial disease (Engel 1980) is a helpful conceptualization that incorporates all known components of etiology. This model is presented to adolescent clients within educationally focused treatment groups and appears to be both readily understood and intuitively accepted as an organizing conceptual framework for further exploration of an adolescent's individual involvement with chemicals, patterns of use, and family and social influences on use patterns.

In summary, drug abuse and chemical addiction are viewed as manifestations of underlying psychosocial vulnerabilities that may also be strongly influenced by biological, familial, and social factors that, once behaviorally established, present a relatively homogeneous pattern of symptoms and behavior. This pattern varies with respect to individual differences, level of drug use, and duration of drug abuse but does include behavioral deterioration, character disorganization (including a disinhibited expression of anger and aggressive impulses and an increase in acting-out behaviors), increased mental preoccupation with drug use and behaviors associated with the obtaining of and opportunity to use drugs, and finally the physical, mental, spiritual, and emotional deterioration of the individual. This model views drug abuse and chemical addiction in some instances as attempts by the individual to self-medicate overwhelming affect in the absence of alternative coping mechanisms.

As previously described, the actual treatment format is varied and includes multiple modes of care. Common to the various modalities is the counselor's use of psychodynamic interpretation of resistance and the empathic exploration of ambivalence toward abstinence and treatment. This approach is most similar to the techniques of motivational interviewing (Miller and Rollnick 1991) and the transtheoretical approach of Prochaska and DiClemente (1984). The clinical techniques common to these approaches— including eliciting ambivalence, reframing, providing advice and empathic feedback, and using a directive yet nonconfrontational approach—are employed as powerful therapeutic tools during assessment, initiation, and active treatment phases. As in the Minnesota Model, adolescent clients' dishonest, manipulative, exploitive, or drug-using behaviors are directly confronted; however, this limit setting serves to allow the client the access to affect required for true change to occur through the disruption of the established pattern of projection of affect and acting out. Similar to traditional psychodynamic models, the counselor employs techniques of dynamic interpretation of resistance, transference, and acting-out episodes, albeit in the context of a treatment approach, which is actually quite directive and firm in setting limits with the adolescent client.

Borrowing heavily from the theoretical framework and resultant clinical techniques of the Motivational Interviewing Model, psychodynamic interpretation of resistance and acting out is added only in the context of a well-established individual relationship between client and counselor. This individual relationship of client and counselor is viewed as the central, unifying framework through which all treatment goals are formulated and implemented. The overall intellectual and clinical structure of the CCATS Model is in fact an eclectic formulation that integrates the compatible techniques of the models of stage change/transtheoretical; psychodynamic; and traditional, Minnesota Model, or 12-step recovery model techniques.

The model differs most from a confrontational, traditional chemical addiction model where a client's resistance or ambivalence can be framed as a "lack of willingness to surrender" or as a symptom of denial or willfulness. Ambivalence within the integrated model is viewed as normal and predictable and as an important part of the process of initiating abstinence and maintaining sobriety. The use of empathic, reality-focused feedback on the part of the counselor is seen as aiding in the adolescent client's own self-exploration and ultimately self-motivation toward behavior change. This treatment approach is also differentiated from a traditional psychodynamic model in which the counselor declines an active, directive approach and the focus is solely on underlying dynamics and psychological vulnerabilities beneath drug abuse to the exclusion of direct questioning and exploration of the impact of drug use.

The combination of a variety of treatment modalities, including individual, group, and family therapy; educationally focused chemical addiction groups; use of therapeutic challenge (e.g., rock climbing, high ropes course, hiking); expressive arts psychotherapy; goal-setting groups; peer feedback groups; staff feedback groups; relaxation training; and psychopharmacology (when appropriate), create the essential treatment provided with the program. There is also an extensive use of behavior modification techniques within the structural framework of the program, including the use of a "level" status and privilege system and the extensive application of various reinforcement techniques including the celebration of adolescent clients' sobriety "anniversaries" of 30, 60, and 90 days clean and the use of a token system with the award of stickers depicting recovery-oriented "slogans" and sayings and peer and staff positive verbal feedback when adolescent clients have consistently refrained from the use of self-defeating or destructive behaviors and successfully used alternative coping mechanisms.

The encouragement of peer leadership and the nurturing and teaching of leadership skills are also essential aspects of the treatment format. Techniques include assigning responsibility to the senior members of the treatment community for orientation to treatment structure, rules and use of 12-step support groups and teaching of appropriate alternative coping mechanisms to drug use, and other acting-out behaviors through peers' disclosure of personal experiences with each other in group and informal settings. The counselors serve as guides for this process, but the adolescent clients themselves are delegated the responsibility for these tasks.

Adolescent clients' use of 12-step support groups is monitored through the creation of daily recovery goals that are behavior specific to attending meetings, associating with new "clean" peers, and acquiring an AA/NA or CA sponsor (a senior member of the recovery group who acts as a guide and provides individual support). Finally, bibliotherapy is also an important part of the structural format of the program. Adolescent clients are given books, pamphlets, and a personal recovery workbook that has worksheets and didactic materials on relapse prevention (RP), the biopsychosocial model of addiction, the self-medication hypothesis, effects of AOD on the body and mind, effective management and expression of anger, and various topics related to recovery from addiction. The completion of several of these required reading assignments and consistent attendance at 12-step meetings are included as key criteria (in addition to individualized treatment goals) to obtaining an increase in the client's level in the status system.

Adolescent clientsÕ use of 12-step support groups is monitored through the creation of daily recovery goals that are behavior specific to attending meetings, associating with new "clean" peers, and acquiring an AA/NA or CA sponsor (a senior member of the recovery group who acts as a guide and provides individual support). Finally, bibliotherapy is also an important part of the structural format of the program. Adolescent clients are given books, pamphlets, and a personal recovery workbook that has worksheets and didactic materials on relapse prevention (RP), the biopsychosocial model of addiction, the self-medication hypothesis, effects of AOD on the body and mind, effective management and expression of anger, and various topics related to recovery from addiction. The completion of several of these required reading assignments and consistent attendance at 12-step meetings are included as key criteria (in addition to individualized treatment goals) to obtaining an increase in the clientÕs level in the status system.

Individual sessions that last 20 to 30 minutes take place once a week. The importance of individual therapy is secondary to group treatment. In fact, the focus of individual treatment is most often on creating and updating the adolescent client's treatment plan, discussing the goals the adolescent client has chosen for group, and discussing family treatment and recovery for the week. Transference phenomena are interpreted, but the emphasis is on the adolescent client's effective use of group therapies and the establishment of a safe and supportive therapeutic alliance that the adolescent client can view as a central, unifying anchor within the context of an intensive, challenging, group-focused treatment structure. Although the relationship between the adolescent client and his or her counselor within the individual session is viewed as important, the adolescent client has been referred to the CCATS program specifically because of his or her need for a higher level of structure and containment than individual treatment can offer. As adolescent clients are for the most part in various stages of acting out their emotions and conflicts, the goal of the entire treatment program can be in essence described in a quotation from the program coordinator, "By the time adolescents can make good use of the individual session they are ready to be discharged from our program" (Walczak, personal communication, 1991).

Adolescent clients participate in group psychotherapy sessions that last 1-1/4 hours three times a week. Group size ranges from four to eight members with two therapists serving as coleaders. Adolescent clients are expected to create a goal each week to serve as the structure and focus of their group work, although adolescent clients are actively encouraged to bring in any issue that is of importance, particularly those impacting their abstinence from alcohol or other drugs or urges to act out in self-destructive ways. The model of group therapy utilized within this model most closely resembles Modified Group Dynamic Psychotherapy (Khantzian et al. 1990), a technique pioneered at the Harvard Cocaine Recovery project with adult drug abusers. Specifically, traditional, expressive, ego-supportive psychotherapy is expanded to include direct exploration and interpretation of clients' difficulty managing affect, cravings for drugs, resistance to the use of social supports (e.g., 12-step participation), and the connection between the experience of intense affective states and the activation of cravings for AOD. The counselors serve to interpret group process, maintain behavioral boundaries, and provide feedback and interpretations. Important to the group therapy treatment is use of a separate feedback group in which group members give one another very specific feedback on their level of participation within the group therapy and their progress toward achieving sobriety tasks. This feedback is provided in a highly structured format, and peer feedback together with staff review of individual progress in treatment determine the adolescent clients' achievement of advancement within the levels system of the program.

There are four specific chemical addiction groups per week, two of which focus specifically on education regarding the biopsychosocial model of addiction, RP: (1) history of, orientation to, and effective use of outside 12-step support groups; (2) physiological aspects of drug effects and addiction; (3) identification of affect and the use of cognitive and behavioral techniques for management of affect of anger as an alternative to acting out; and (4) topics generated by the adolescent clients' specific requests for information. Each adolescent client receives a recovery workbook created by the treatment staff. In it are worksheets addressing the above-named topics, literature describing various concepts in depth, and blank pages for adolescent clients to use in recording individual recovery goals and behavioral progress toward those goals. Daily recovery goals might include attending an AA or NA meeting, accomplishing a recovery reading assignment, or terminating an unhealthy peer relationship or establishing a new, supportive one. Each goal is chosen by the adolescent client, and he or she receives verbal reinforcement and feedback from peers and staff along with a visual reinforcement on a goals board that is prominently displayed within the community. Adolescent clients also process cravings for AOD, "relapse dreams," and RP plans within these groups.

Although a description of the other treatment modalities employed in the treatment of dually diagnosed adolescent clients is beyond the scope of this chapter, the importance of these other modalities must be emphasized. Other approaches to treatment utilized at CCATS include family therapy, expressive arts, and pharmacotherapies, as well as activities like the therapeutic challenge program. Family therapy stresses as primary goals developing a collaborative relationship with the adolescent client's parents, recognizing the familial patterns of denial and enabling, and identifying the addictions of other family members. The expressive arts program provides a means of accessing feelings that adolescent clients may otherwise deny, suppress, or lack words to describe. The therapeutic wilderness challenge program is used to promote group cohesiveness and to aid adolescent clients in confronting fears rather than avoiding them by using drugs or other maladaptive coping mechanisms. Finally, given CCATS' affinity for the self-medicating hypothesis as a precipitant for drug abuse, pharmacotherapy is often used as an adjunct to treatment to address underlying disorders that are frequently depressive in nature.

The CCATS Model was specifically designed for a day treatment or partial hospital setting. The program provides integrative case management to link the educational programming that adolescent clients receive each morning through their local school system with their clinical treatment and 12-step program work.

The average length of stay in the CCATS program is 12 to 16 weeks, with actual length varying according to clinical need. Treatment plans are reviewed twice a week to discuss and document the adolescent client's progress toward achieving treatment goals and discharge planning in relation to the adolescent client's accomplishments, or the clear indication that the adolescent client needs a higher level of treatment or change in treatment plan because of noncompliance or an increase in symptoms or behavioral difficulties.

As noted in the description of the program detailed previously, other therapeutic modalities, such as pharmacotherapy, family therapy, and expressive arts therapy, are considered to be not only compatible with but also essential to the success of treatment.

As previously discussed, special emphasis is placed on participation in AA/NA or CA for drug-abusing clients. Adolescent clients are informed before beginning treatment that they will be expected to attend at least three 12-step meetings a week outside of program hours. Again, their participation is encouraged through peer feedback and the behavioral techniques described earlier. Adolescent clients who have a drug-abusing parent are educated about Alateen groups, and parents of adolescent clients in the dual-diagnosis program are themselves referred to Al-Anon for additional support and education regarding self-care, boundary setting, and help in ending enabling behaviors. Essentially, adolescents readily attend 12-step meetings and use the groups on a variety of levels, including social support and normal ego-supportive socializing; for identifying positive mentors, role models, and parental figures; for educational help, support, and advice in remaining sober; and for enjoyment and stimulation. Adolescent clients are encouraged to obtain an AA/NA or CA sponsor, that is, a person with long-term sobriety who acts as a guide and who in general will be available for support 24 hours a day during the adolescent client's active treatment and after discharge, thus providing continuity and direction.

For many adolescent clients, the 12-step programs serve as a surrogate family, where their original family system may be chaotic, devaluing, or nonexistent. The authors have witnessed many adolescent clients who were removed from their families and in various stages of foster care or surrogate care were able to use the 12-step programs as an effective means of obtaining nurture and structure.

Within the context of CCATS' emphasis on the use of 12-step meetings, each adolescent client is encouraged to embrace a conceptualization of these groups and the spiritual focus of the 12-step philosophy that reflects his or her own personal values, spiritual orientation, and individual preferences. The adolescent client is continually encouraged to examine and to express his or her ambivalence toward the 12-step programs without fear of consequence or reflection in privileges or status in the program. It is of clinical interest to note that in this environment, one that allows and acknowledges the importance of ambivalent feelings and their expression, there is very little behavioral resistance to 12-step attendance.

The general educational requirements of the staff include an advanced degree in social work, expressive arts therapy, psychology, nursing, or counseling and specific continuing education and inservice training in chemical addiction and drug abuse treatment. A minimum of 3 years of clinical experience with adolescents is required, as is ongoing clinical supervision.

The clinical coordinator of the Adolescent Dual-Diagnosis Service is a certified alcohol and other drug abuse counselor with 8 years of psychiatric clinical experience.

Particular emphasis on the use of dynamic examination of the therapist's own countertransferential experiences and reactions to clients' transference is an important aspect of clinical supervision, which occurs both individually between the counselor and a senior clinical supervisor and in the context of the coleader relationship in group therapy.

Counselors within this model are required to have a high level of understanding and acceptance of the validity and importance of psychodynamic techniques, along with a willingness to be introspective and to a certain degree able to acknowledge unresolved personal conflicts, which may be found to block clinical sensitivities within the present. Because of the eclectic nature of the various treatment modalities employed within this model, counselors must be skilled and cross-trained in various modalities and techniques and must have the personal characteristics of flexibility and intellectual fluidity to function in multiple roles.

The status of a counselor as being in recovery from alcoholism or addiction or having firsthand knowledge of Al-Anon recovery is not essential to being effective. However, the intricacies of experience awarded through an individual's participation in his or her own recovery program can probably not be equal to a solely intellectual pursuit of the same knowledge. Counselors within this treatment program who are in recovery from addiction or coaddiction do not participate in free self-disclosure of their status and most specifically refrain from the disclosure of significant information regarding their history of drug use or other significant personal history. Inevitable direct questions from adolescent clients regarding both the counselor's recovery status and specific details of the counselor's history of drug abuse or previous treatment experience are usually answered interpretively, although the individual counselor is free to disclose his or her status as a recovering person. It appears that adolescent clients react favorably to recovery-oriented feedback from nonrecovering staff members; however, the level of knowledge, comfort, and conviction a counselor has regarding the content of educational material or directive or interpretive feedback may be the key indicator of the effectiveness of the counselor's impact. In short, for a counselor to impart effectively the philosophy of a world view that holds central the belief in using a power greater than one's self, either socially or through spiritual means, he or she must have a similar personal investment in the value of this world view. Similar to the means through which self-esteem is subtly and consistently imparted to a child through the actions and words of a healthy, caring parent, the adolescent client will "catch" the value of the 12-step philosophy through the individual relationship and teaching of a counselor who lives by his or her espoused beliefs.

The personal characteristics most ideally suited for this treatment approach include the qualities of warmth, genuineness, empathy, clear personal boundaries, and a high degree of self-awareness and psychological mindedness. In addition, attributes of flexibility and humor and the ability to set firm behavioral limits in a nonjudgmental and nonpunitive manner are very useful. The carefully restrained use of personal charisma and humor aids the counselor in motivating adolescent clients and engaging resistant clients in a working therapeutic alliance. However, the counselor must always be aware of the extent to which the use of these particular characteristics may be in the service of gratifying his or her own narcissistic needs. Again, it is a function of the carefully structured supervision inherent in this clinical model that would aid in the most effective and nonmanipulative use of charisma and humor with adolescent clients.

A skilled counselor must be able to maintain a sense of personal integrity and a strong sense of self to be able to deflect, tolerate, control, and interpret accurately the projected identification and projection of rage and self-loathing typical of adolescent clients with borderline or narcissistic features.

Psychologically oriented self-awareness and clear personal boundaries also aid the counselor in minimizing his or her acting out of unresolved dynamic conflicts and having his or her own insufficient narcissistic reserves gratified within the therapeutic relationship through idealization and misuse of power. The same personal strengths are again called into play when a counselor must refrain from failing to set appropriate limits, again in the service of regulating his or her own internal narcissistic stores. When a counselor sets a limit with an adolescent client who is acting out, the client may attack the counselor verbally in an attempt to avoid experiencing affect. A counselor who struggles with maintenance of self-esteem will inevitably err when setting limits. The use of careful clinical supervision can aid in the continuous self-examination of these potential vulnerabilities.

Although the personal characteristic of flexibility is difficult to define operationally, it is clearly a necessary personal attribute when working closely with adolescent clients who act out through means of verbal abuse, physical aggression, and self-destructive, self-injurious means. Flexibility is key in avoiding the ever-ready opportunity to engage the adolescent client in subtle or overt power struggles, program rules, personal responsibility for behavior, or a variety of clinically relevant topics.

Behaviors proscribed within this approach are those related to direct, unyielding confrontation of resistance or passive acceptance by the adolescent client or the adaptation of a nondirective stance toward the adolescent client's resistance, acting out, or suspected drug abuse. The counselor who is in his or her own recovery is also prevented from relating details of his or her former drug use and specifics of his or her own personal recovery, as it is viewed as deflecting the adolescent client's focus from his or her own treatment. Counselors should refer adolescent clients to 12-step meetings where they will be exposed to socializing and self-disclosure of other recovering individuals. The counselor, while not rigidly refraining from any self-disclosure, must remain a neutral object for the adolescent client's transference.

Other proscribed behaviors include using any statements, interventions, or techniques that involve humiliating, shocking, or pressuring the adolescent client to behave in ways that violate his or her free will and personal integrity. The counselor should never use derogatory language, accuse a client of character defects, demand that a client "surrender" or "work the steps," or use any other such controlling behavior. The use of shaming techniques constitutes emotional abuse, not treatment. The counselor also is prohibited from colluding with an adolescent client's active relapse or possible drug use by refraining from holding him or her responsible for his or her own recovery and behavior or by withholding such information from other group members.

Coleaders meet on a regular weekly basis (with a senior clinical supervisor) to examine the group process and aspects of counselors' relationships as they relate to countertransferential feelings and individual perspectives and feedback on the actual techniques employed by coleaders during the group. These techniques were implemented and supervised by the initial creator of the program, Dr. Richard Salwen, who asserts that "The quality of the clinical work is dependent on the quality of the clinical supervision" (Salwen, personal communication, 1991).

Within this model the counselor has multiple roles, serving as teacher, guide, consultant, therapist, and coach to the adolescent client in a journey of self-knowledge. The counselor is seen initially serving as a charismatic coach or directive guide as the adolescent client becomes accustomed to the boundaries and limits of treatment, establishes rapport with staff and peers within the treatment program, and experiences initial success in establishing minimal treatment goals within the group setting. Even given the role of the counselor as guide and initial leader, within this treatment approach the adolescent client is consistently reminded that he or she is the central agent of change within his or her own life.

The adolescent client generally talks more during group and individual sessions. There are exceptions, however, during didactic presentations and in the earliest phase of treatment initiation. Here the counselor may choose to be quite directive and impart general information and teaching regarding program rules, structure, and expectations, both in the service of communication of this information and in the establishment of an initial rapport or relationship with the adolescent client.

The counselor is quite directive, and the limits and boundaries of the CCATS structure serve as a vehicle to impart structure and limits to the adolescent client. Within the individual relationship, the counselor strives to be directive without committing the errors of control or disengagement described earlier. Adolescent clients who idealize the counselor and request opinions and direct advice are asked to examine their own feelings and to express their own thoughts or request feedback from the counselor or the group to diffuse the role of counselor as omnipotent and to encourage and foster the strengths of the other members of the group and the group process itself.

The quality of the therapeutic alliance (TA) between the counselor and the adolescent client is the most essential aspect of treatment, and great care is taken by the counselor to create a safe and predictable holding environment for the client's concerns, affect, and behaviors. The counselor does so by creating clear and consistent boundaries within the individual relationship. Thus, the counselor remains a stable, dependable presence with the adolescent client whenever possible. The counselor extends this sensitivity to the individual relationship in various ways, including anticipating a client's possible reactions to events such as the counselor's vacations, illness, or other absences from the treatment milieu.

The counselor also seeks to develop a strong initial alliance with the adolescent client through displays of active interest in the client's experience of treatment and recovery (i.e., direct questions about symptoms, level of participation in self-care, attendance at 12-step meetings). Humor and interpretation of resistance are used in place of direct confrontation, and the alliance is built and sustained by each interaction, in which the counselor demonstrates an ongoing interpretive sensitivity. The TA is also built through appropriate and consistent limit setting, as it is the underlying assumption that the adolescent client who has difficulty with self-regulating impulses feels comforted by external limit setting and may use this aspect of TA to internalize limits and improve self-regulation of impulses and affect.

A TA where the adolescent client has a strong negative transference, or one that is initially weak, is managed interpretively, and the client is encouraged to discuss his or her resistance openly. The counselor's goal is to strengthen the TA through interpretation of the client's transference, and the very act of accepting the client's experience without judgment often serves to enhance the working alliance.

The CCATS Model is specifically designed for a dually diagnosed adolescent population; however, the aspects of the client-counselor relationship are applicable for use with any population. The program has been successfully employed with clients who have abused a wide range of drugs, including primarily alcohol, marijuana, hallucinogens, heroin, amphetamines, and inhalants.

Individuals who are not well matched to this treatment approach include those adolescents with extreme behavioral problems (e.g., frequent violent outbursts), those with no desire to initiate or maintain abstinence from use of mood-altering drugs, and those with pervasive intellectual or physical disabilities. As the integration of 12-step-oriented treatment and psychodynamic treatment techniques demands that an adolescent client be able to use abstract thinking, the client must have intellectual functioning in the low average to average range. It does not appear that adolescent clients need to have reached formal operations to benefit from treatment, and in fact many adolescent clients are observed progressing from concrete operations to more formal, abstract thinking ability while exposed to the highly abstract and stimulating communication that occurs within the treatment milieu. Adolescent clients who have pervasive learning disabilities or who are significantly impaired organically will also be poorly suited to this approach and would require a modified program, as well as extensive use of specialized cognitive retraining and rehabilitation services, in addition to the treatment.

The scope of this chapter does not allow for a thorough description of the assessment techniques employed within this counseling model; however, a brief description of the structure and clinical philosophy of the assessment process serves to illustrate further the relationship of adolescent client and counselor. Assessment within this model is viewed as the first stage of treatment and the data collection as equal to the establishment of the therapeutic alliance and the enculturation of the adolescent client to the treatment process through basic teaching of boundaries, expectations, and language commonly used in treatment. As many adolescent clients will be experiencing a psychiatric and drug abuse evaluation for the first time, special consideration is made to proceed slowly and with empathy to the anxiety, fear, and affect of the adolescent client and his or her family members. The adolescent client is assessed for drug abuse by conducting a urine drug screen, by using semistructured clinical interviews, and by performing standardized psychological testing employing the Personal Experiences Inventory and the Reynolds Adolescent Depression Scale. The counselor remains aware that an adolescent who is a drug abuser and who is chemically dependent will consciously and unconsciously minimize the extent of his or her drug use and its negative behavioral consequences during the assessment process. For this reason, careful attention is paid to collateral sources of information (e.g., family members, probation officers, school personnel) when they are available.

The adolescent client's drug abuse history is considered within the context of a psychosocial history with an emphasis on the following: trauma, family functioning and dynamics, family history of drug abuse and psychiatric illness, involvement with the law, spiritual life, and present level of motivation toward abstinence. The counselor is seen as ideally working in partnership with the adolescent client and his or her family in establishing a working alliance, obtaining information, providing feedback, and formulating a treatment plan based on the data obtained.

The format for treatment sessions varies with regard to the modality of treatment within the overall treatment model.

A typical chemical addiction group begins with participants discussing their daily sobriety goals and receiving peer feedback for either their accomplishments or resistance to completing their self-established goal. The format of the group then shifts to an interactive/didactic style, where the counselor presents information on such topics as RP, use of 12-step support groups, and the first three steps of the 12 steps. The counselor uses circular questioning, making participants answer open-ended questions on the information as it relates to their own experience and recovery, or the counselor may elicit resistant group members to describe their ambivalent feelings. Group process generally addresses resistance in the most effective manner, and the counselor takes a back seat to the natural process of the group except to limit inappropriate behavior, aggressive expressions of rage, and so forth. Group members also set behavioral limits for themselves and are particularly adept at recognizing warning signs of relapse in one another. The group ends with a brief commentary by the group leaders on the topic discussed and the process of the group.

A typical group session might involve a discussion around the use of selective cognitive schemata, either to "compare in" to other people in AA, treatment groups, or in general, or the more common cognitive schemata of using judgmental self-statements that separate one's experience from others ("comparing out"). The interactive lecture focuses on the self-statements made when choosing to distance one's self and feel either superior or inferior in experience or unique in terms of affect, fears, and so on (comparing out) versus the self-statement made when attempting to feel connected to and empathizing with another's experience, feelings, or opinions (comparing in). Adolescent clients are asked to think of their most typical self-talk patterns, particularly as they relate to their level of honesty, vulnerability, and self-disclosure of drug cravings, affect, ambivalence and fears in the treatment setting and in the 12-step meetings. Sessions are semistructured and focus on the here-and-now group process taking precedent over a structured lecture format. The importance of education is not deemphasized in this context; however, the counselor's role as teacher is complementary to his or her role as supportive and interactive psychotherapist.

Treatment sessions typically focus on topic areas directly related to adolescent clients' drug abuse and its relationship to other symptoms and behavioral consequences. Within this broad heading frequent topics include:

• Self-medicating aspects of drug use and the relationship of depressive symptoms to drug use (Khantzian et al. 1990).

Within this topic area, adolescent clients discuss not only their use of drugs but also related self-destructive behaviors that can be seen as self-medicating (e.g., self-mutilating behaviors, sexual acting out, shoplifting, acting-out anger). Clients gain insight into the interrelated aspects of all these behaviors as attempts to self-manage and medicate overwhelming affect. Alternative coping mechanisms are introduced by the counselor through questioning of clients regarding their own strengths and abilities used to avoid these behaviors.



• Creating a "chemical history" or truthful description of all mood-altering drugs used, as well as positive aspects of use and negative consequences related to use.

This topic allows for the enhancement of cognitive dissonance related to drug use as a coping mechanism. In particular, adolescent clients are encouraged to describe and acknowledge the positive and, at times, adaptive aspects of their previous drug abuse as a means toward further insight into the self-medicating aspects of use, as well as to avoid the "splitting off" of the good aspects of drug use from the therapeutic alliance.



• Discussing orientation and resistance to 12-step attendance.

Adolescent clients are given structured behavioral expectations for 12-step attendance that are nonnegotiable as part of treatment; however, the clients' ambivalence and resistance to these aspects of treatment are not only anticipated but also elicited in group and individual sessions. The underlying assumption of the counselor is that adolescent clients' fears, anger, or defiance of this aspect of treatment are significant to underlying vulnerabilities of self and fears of the unknown aspects of recovery. Attending 12-step meetings is seen as an educational experience, and clients are not forced to adapt any of the philosophical or social aspects of these meetings. Thus, resistance can be seen as emotionally based. (See section 8.3 for a brief session description that illustrates this topic in a session with a resistant adolescent.)



• Identifying and understanding relapse triggers and how to manage urges to use drugs.

Within this topic area, adolescent clients disclose and discuss their relapse experiences and share alternative coping mechanisms.



• Relating family issues to drug abuse and psychiatric symptoms.

Adolescent clients create a genogram with a staff member or discuss family history of drug use, depression, and other relative behaviors. The research supporting the genetic factors related to psychiatric illnesses and drug abuse is presented. Clients are encouraged to see the patterns of strengths and vulnerabilities within their families and in doing so acknowledge and discuss their own struggles to separate from family patterns.

Within the Dynamic Integrated Treatment Model, group sessions and the focus of treatment goals are highly structured in order to elicit clients' resistance and help them move toward behavioral change through resolution of the underlying issues creating resistance. Each day in treatment, adolescent clients are asked to create a specific treatment goal relative to their establishment of abstinence, AA/NA attendance, family issues, and so forth. These goals are reviewed within a community discussion that includes all staff and clients; the client then continues work on these goals throughout the remaining three therapeutic groups of the day.

The interaction between counselor and client within this model is relatively unstructured as the counselor follows the process and content of what the client brings into the group or individual session vis a vis treatment goals. The counselor creates structure within the session by maintaining an interpretive role that helps guide the client closer to the underlying issues of psychological vulnerabilities and to the dynamic issues of loyalty to parents and important others and conflicts regarding the client's movement toward health.

Following is a brief transcript of a session with a dually diagnosed 13-year-old girl that clearly illustrates how the counselor maintains this interpretive structure and position while following the client's lead with regard to content and process of the session. This adolescent client's daily goal was to discuss attending AA meetings and talk about her feelings regarding this attendance. Of note is that the counselor was aware of the adolescent client's family history of having an alcoholic mother and a sibling who was addicted to drugs. Both these family members were still actively using drugs at the time of this young woman's treatment. Also, this young woman had experienced the death of a younger brother 5 years previous to her treatment.

Client: I am not going to any AA meetings. This is stupid, and there is no way I am going, so don't even bother with the psychobabble.

Counselor: Something really makes you angry about the rule about going to meetings. I wonder what really gets to you about that?

Client: I told you, it is bulls—t and I am not going. I hate this place.

Counselor: Seeing how upset you are I wonder what it might be like being asked to go to AA to take care of yourself when your Mom and your brother are still using. No one is helping them. It's really not fair that you have to learn to get well and take care of yourself.

Client (softening): Yeah. Why don't they have to go? I am only 13!

Counselor: It would be my dream for you that your whole family got healthy together. (Pause. Client nods.) But it looks like you might have to have the courage to be the first one. You're right, it's not fair.

Client (tearful): It's so hard. No one gets it.

Counselor: Your Mom and brother don't get it right now, you're right. It must be really hard to trust what the staff here says over them right now.

Client (nods, still tearful): I wish they would come to meetings with me.

Counselor: That would be great. (Pause.) Will you consider going to the meetings here with some of your peers and continue talking about all the things you just said to me?

Client: Yeah, I guess for now.

In this brief transcript, the adolescent client's unconscious resistance issues are helped to come into conscious awareness by the counselor's sensitive integration of underlying dynamic issues into the feedback to the adolescent. The client, through setting the goal of AA attendance, was able to present her unconscious resistance and move toward separation from unhealthy family members and greater self-care through the exploration of this resistance. This client was ultimately able to maintain sobriety, attend AA, and experience significant improvement in her self-care both physically and psychologically.

In this model, resistance is always seen as meaningful. The counselor not only structures feedback toward the issue of 12-step attendance and the client's intense resistance to this but also broadens the topic to integrate the threatening and overwhelming affect relating to the client's resistance to self-care.

The issues of denial, resistance, lateness, and missed appointments are viewed not so much as clinical problems but as various manifestations of the adolescent client's ambivalence toward abstinence, recovery, and emotional healing. Within this counseling style, these issues are seen not only as normal and predictable but also as inevitable and valuable. Behaviorally, adolescent clients are given limits and are punished for lateness or absences through a drop in their "level" status and a discussion of their acting out within the community. Adolescent clients are encouraged to examine their ambivalent behavior and to formulate their own hypothesis regarding its nature, cause, and solution.

The more subtle issues of denial and resistance are dealt with in the clinical context of each adolescent client's progress in treatment. Again, he or she is encouraged to explore the ambivalent feelings rather than to deny, repress, or distort personal expression in order to conform to the expectations of the counselor.

The CCATS Model has built into it policies and procedures for dealing with crises. Included in the services is access to a 24-hour crisis intervention service through the hospital for adolescent clients and their families. Adolescent clients can also be hospitalized briefly in the inpatient psychiatric unit when they are experiencing acute depressive symptoms and active or passive suicidal ideation. The crisis experience is always integrated into the adolescent's relationship with his or her individual counselor and within the CCATS milieu.

The response of the counselor to an adolescent client's slips or relapses is considered a critical aspect of both the overall treatment philosophy and, more centrally, the individual relationship between the counselor and his or her client. The counselor responds in an empathic manner, helping the adolescent client explore the precursors to the relapse and allowing him or her the opportunity to explore feelings of ambivalence toward abstinence and the full range of feelings toward the relapse experience. The adolescent client often views the relapse experience as pivotal to his or her ability to commit to abstinence after exploring the actual impact of the drug use on his or her behavior, feelings, and relationships. The counselor frames the slip as an opportunity to learn and to commit to abstinence, without minimizing the impact or seriousness of the potential to relapse in the future.

The involvement of family members or guardians, as described previously, is considered essential to the adolescent client's success. A unique structure of the CCATS Model is the inclusion of the adolescent's AA sponsor in treatment. Adolescent clients are required to obtain an AA or NA sponsor within the first weeks of treatment and in turn to invite their sponsor to participate in a conjoint meeting with their parents at home and with their primary counselor during program hours. This involvement ensures that adolescent clients obtain a sponsor and also communicates the importance that the clinical staff imparts to the use of outside supportive relationships in the 12-step programs to the ongoing sobriety and emotional well-being of clients. An indirect message is also communicated to the adolescent client within the individual client-counselor relationship through this involvement: the fact that the counselor can tolerate the caring and affectionate relationship of the adolescent with other supportive adults. The healing nature of this posture is imperative for adolescents who have had parents or caregivers with borderline or narcissistic pathology.

For treatment to have longstanding impact on adolescents who suffer from comorbid psychiatric and drug abuse disorders, the adolescent client's longstanding and overdetermined psychological vulnerabilities must be addressed. Chemical addiction and drug abuse should be addressed through a structured psychoeducational treatment format that incorporates the techniques of psychodynamic interpretation of resistance, the acceptance of ambivalence and relapse as developmental aspects of the recovery process, and the referral of clients to 12-step support groups. Within the context of a supportive and empathic individual relationship with the adolescent client, the uncovering and reexperiencing of repressed affect that appears to predate and coexist with chemical addiction is achieved through the setting of firm, consistent, and reliable limits and boundaries that include reframing and interpreting the adolescent client's resistance to experience affect. For adolescents who therefore almost exclusively use maladaptive coping mechanisms of an externalized nature (e.g., drug abuse, conduct-disordered behavior), the treatment goal of developing the alternative coping mechanisms of identifying, experiencing, tolerating, and verbalizing affective stages of anger, frustration, sadness, and disappointment becomes a focus of treatment. This focus on affective "recovery" is accomplished only within the context of a trusting and valued individual relationship, where the client suspends (if only momentarily at first) his or her complete reliance on personal defensive postures. Through this trusting relationship, and the suspension of defensive postures, the adolescent client can begin to learn and rehearse the world view described within the 12 steps of AA, where the client, after admitting the futility of a delusion of omnipotent control of reality, comes to believe he or she is not alone and can rely on others for care and nurturing to withstand considerable psychiatric distress without acting out in an effort to discharge this affect. The counselor must receive ongoing psychodynamically oriented clinical supervision to maintain the level of introspection and sensitivity required of the fluid role expectations of this model and the intense emotional requirements of firm and consistent limit setting with clients who devalue, use physical and verbal acting out, and resist the expression of affect other than anger.

Although it is this individual relationship that is viewed as the context through which many aspects of behavior change are attributed, the structure and content of group experiences are designed to allow clients to explore ambivalence and motivation and gain insight into the impact of the use of drugs on their lives. A cognitive, behavioral focus on establishing abstinence sets the stage for further exploration of the symptoms related to the assumed causative factors of drug addiction. Although these underlying causative factors are seen as secondary to the establishment of initial abstinence, the long-term maintenance of abstinence is seen as directly related to the ability of the adolescent client to accept responsibility for self-care; to develop alternative, more mature defense mechanisms; and to begin the lifelong process of affective expression and the establishment of meaningful intimate relationships with others. A phrase used to teach this truth to the adolescent client is often repeated within the treatment milieu, "To stay clean, you must learn to replace your drug of choice with human relationships."

In the context of a warm and supportive relationship between counselor and client, all goals and objectives of treatment are interpreted and created. The counselor becomes the "good-enough" parent who serves as teacher, historian, parent, coach, and guide to the adolescent client as he or she experiences the affect long buried beneath the previously functional defense of chemical abuse.

For the adolescent client to release his or her dependence on the powerful, self-medicating aspects of chemical abuse, the counselor must impart both directly and indirectly the message that human relationships can be hopeful, loving, and supportive. Through exploration of the inevitable disappointments within the individual therapeutic relationship, the adolescent client can learn that the intense affect that may be experienced at these times, transferentially evoking injuries sustained in the context of primary relationships with significant others, can be managed within a world view of ultimate faith in the value of each individual's capacity to give and receive caring and love.

Bukstein, O.; Glancy, L.J.; and Kaminer, Y. Patterns of affective co-morbidity in a clinical population of dually diagnosed adolescent substance abusers. J Am Acad Child Adolesc Psychiatry 31(6):1041-1049, 1992.

Christie, K.A.; Burke, J.E.; Reiger, D.A.; Rae, D.S.; Boyd, J.H.; and Locke, B.Z. Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults. J Psychiatry 145:971-975, 1988.

Deykin, E.Y.; Levy, J.C.; and Wells, V. Adolescent depression, alcohol, and drug abuse. J Public Health 79:178-182, 1987.

Engel, G.L. The clinical application of the biopsychosocial model. Am J Psychiatry 137(5):535-544, 1980.

Fairbairn, W.R.D. Psychoanalytic Studies of the Personality. 7th ed. London: Routledge and Kegan Paul, 1981.

Khantzian, E.J. The ego, the self and opiate addiction: Theoretical and treatment conditions. Int Rev Psychoanal 5:189-198, 1978.

Khantzian, E.J.; Halliday, K.S.; and McAuliffe, W.E. Addiction and the Vulnerable Self: Modified Dynamic Group Therapy for Substance Abusers. New York: Guilford Press, 1990.

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991.

Newcombe, M.D.; Maddihian, E.; and Bentler, P.M. Risk factors for drug use among adolescents, concurrent and longitudinal analyses. Am J Public Health 76:525-531, 1986.

Prochaska, J., and DiClemente, C. The Transtheoretical Approach: Crossing the Traditional Boundaries of Therapy. Homewood, IL: Dow Jones/Irwin, 1984.

Wood, B.L. Children of Alcoholism: The Struggle for Self and Intimacy in Adult Life. New York: New York University Press, 1988.

Special acknowledgment to Fran Walczak B.S.R.N., CCATS Coordinator, for collaboration and supervision in the creation of the dual-diagnosis treatment model.

Elizabeth Driscoll Jorgensen, C.A.C.
Coordinator of Adolescent Substance Abuse Services

Richard Salwen, Ph.D.
Director
Department of Behavioral Health

Center for Child and Adolescent Treatment Services
The Danbury Hospital
196 Osborne Street
Danbury, CT 06877