Scenario: Substance Abuse and Family Issues
Joseph is a15-year old African male living in the USA. He was recently brought to a juvenile assessment center for having been caught with cocaine. Possessing cocaine violated his ongoing probation. Six months ago, when Joseph was arrested and adjudicated, he was placed on one-year probation.
Additionally, he would be receiving outpatient substance treatment based on the results of the assessment carried on the substance. In the outpatient treatment, Joseph did well and advanced through the program easily. There were no relapses and confrontations with authorities. After five months, he graduated from the program.
Ten years ago, Joseph’s chemically independent father was arrested for attempted murder. Therefore, Joseph has not seen his father since then. Joseph feels that he is very close to his mother and elder brother. However, he has no respect for them probably because his mother does odd jobs that pay minimum wage.
In addition to his disrespect, Joseph ran away from home three times when he was aged 10 and 12 years. He does not show remorse to his conducts. Recently, Joseph’s brother ran to a nearby city to escape the dangers of his neighborhood. Joseph has very high intellectual quotient, which ranges above normal. He performs well in school, but he is negligent towards academics.
From the recent incidence, the judge, with the help of social workers from the Juvenile Assessment Center and outpatient treatment centers that treated Joseph, ordered him to a residential abuse treatment instead of a jail term. The two social therapists convinced the judge that the victim deserved another chance of treatment. Given that the victim had completed the outpatient treatment, the judge sentenced him to a residential treatment in a therapeutic community center for adolescents.
Moreover, the judge ordered the family to be attending the weekly multifamily groups that teachings are offered at the residential treatment center. The family had not participated in the previous outpatient treatment program. At the Juvenile Assessment Center, Joseph is assigned a case manager who should visit him weekly. This manager should also link Joseph’s family with the necessary resources to increase the chances of post-treatment success.
The Problem
Substance abuse is a complex problem that remains prevalent and problematic amongst adolescents. It encompasses a broad spectrum of phenomena that involve the specific substances used, range in quantities used, frequency of use, associated problem behaviors, and other influences (Donohue & Azrin, 2012).
The addictive properties of these illicit drugs have important and unique implications for treatment of the resulting adolescent disorders. When compared to other clinical problems, treatments for substance abuse may be influenced by the victim’s social environment, peer pressure, and the availability of the substance. The majority of adolescents that have been influenced by substance abuse show lack of motivation to change and resisting treatment (they enter treatment programs only under court orders)
In the scenario above, two offender categories correspond to the situation of the client and the discernment of the treatment considerations. The offender categories include substance abuse and family problems. The client has been caught with cocaine after having been in a probation program for the same problem.
He is presented to the judge who is convinced by social workers that the victim can change if given another chance. Having been referred to a therapeutic community, the task here is to give a treatment plan, which will help change him while at the center. The treatment should consider the other problem, viz. his disrespect towards his family members
Juvenile offenders have unique treatment needs, and thus the treatments designed for adults have to be modified slightly to suit the cases of adolescents. It is important for the family to be involved in the interventions targeting the youth. For the case of Joseph, the following are some behavioral treatments that could be employed while at the community therapeutic center.
Multi-Systematic Therapy (MST)
This method addresses the “factors associated with the extreme anti-social behavior shown by adolescents who abuse drugs” (Galanter, 2011, p. 81). The factors are grouped into the characteristics of the child, the family, friends, school, and the surrounding.
The characteristics of the child may be favorable towards the drug, the family may have poor standards of discipline or have conflicts, the friends may be drug addicts, and the surrounding may have a crime culture. The victim can be involved in this treatment from natural settings like home or any other convenient place.
This method is known to reduce adolescent substance abuse in at least six months after the treatment. Galanter (2011) posits, “Fewer out-of-home adolescent treatments and incarcerations save the cost of offering this intensive service” (p. 83). They also help in maintaining low caseloads to the therapists. This method could suit Joseph’s case because the family has a history of conflicts and poor standards of discipline.
Multi-Dimensional Family Therapy (MDFT)
This method is a “family-based outpatient treatment process for adolescents who abuse drugs” (Walters & Rotgers, 2012, p. 84). This method views substance abuse from the perspective of networks that influence the victims. Such networks include family, community, or friends. MDFT for adolescents suggests the reduction of undesirable behaviors while enhancing the suitable ones in multiple ways and disparate settings. The method has both personal and family sessions held in different locations.
In individual sessions, “nurses engage the victim on developmental tasks liked decision-making, negotiation, and problem-solving skills” (Walters & Rotgers, 2012, p. 95). These sessions equip the victim with vocational and communication skills for voicing out their internal feeling and thoughts so that they can deal properly with stressing moments in life.
In sessions that parents are involved, “nurses examine the styles of parenting to teach parents to learn to differentiate control from influence so that they can have positive and appropriate influence on their children” (Donohue & Azrin, 2012, p. 106). As this method touches both the adolescent the parent, it would also suit the case of Joseph. However, his networks of influence are not clear, and thus it may be ineffective.
Brief Strategic Family Therapy (BSFT)
This method seeks to eliminate family interactions that favor substance abuse among adolescents. Examples of such interactions include conduct problems at home, rebellious behavior, aggressiveness, or risky sexual behaviors. It is a “family systems approach, which assumes that the behaviors of the family members are interdependent” (Donohue & Azrin, 2012, p. 98).
The method assumes that the symptoms of one member indicate what else is happening in the family. In this case, “the BSFT traces the patterns of the family behavior that could be related to the adolescent’s problem, and assists in changing that behavior pattern” (Donohue & Azrin, 2012, p. 102). This method proves to be very flexible, and thus it can be applied to a wide range of family situations, settings, and treatment modes.
Considering Joseph’s situation, his problem could be attributed to his parents’ behavior patterns. His father was convicted of attempted murder while his mother attempts to sell drugs. This method could attempt to change the kind of behavior with the Joseph’s parents. However, the method does not focus much on the victim, who also needs attention (Weisz & Kazdin, 2010). For the method to work in Joseph’s case, it needs to be combined with another method to address the problem.
Functional Family Therapy (FFT)
This method is also based on the family systems’ approach. The method views the victim’s behavior to be created or propelled by the dysfunctional interaction pattern of the family. The main aim of FFT is to “decrease difficult conducts through improved communication skills, problem-solving and parenting skills, and conflict resolution” (Weisz & Kazdin, 2010, p. 73).
Through FFT, the method involves the adolescent and one member of the family. The method engages families in the process of treatment, and it enhances their motivation for change. The method also changes the behavior of the family members using contingency management techniques, behavioral interventions, and communication.
Given the family issues in Joseph’s case makes this method very suitable for solving his situation. The method involves the victim and at least one family member, and thus it can improve the family situation, especially communication as well as changing the conduct of Joseph.
Adolescent Community Reinforcement Approach and Assertive Continuing Care
In this method, the juveniles and their parents support the process of recovering by increasing family educational and social reinforcements. Therapists assess the “victim’s needs and the level of functioning before choosing the best procedure that would address problem-solving, help in coping, and improve communication skills” (Miller, 2013, p. 127). The client is encouraged to participate actively in social and recreational activities. The process involves role-playing and behavior rehearsals.
This method entails other systems to avoid relapse. After an adolescent is discharged from the treatment, the involved therapists visit the client at home regularly for about fourteen weeks. The ACC combines assertive case management services with A-CRA to equip the adolescents and their caregivers with adequate skills to participate in social activities. The description of this method suits in the Josephs case.
Multicultural Factors
Gender
Gender greatly affects the process of obtaining treatment from substance abuse. The treatment process begins by first identifying the problem by the victims, their family, therapists, employers, or any other interested party. The possibility of identifying substance abuse differs between the two genders. For instance, when compared to men, problems of substance abuse among women are less likely to be spotted in a healthcare setting.
Besides, it is less likely that women with substance abuse disorders will be referred to a treatment process from their employers or other institutions. Once the substance abuse problem is identified, some barriers have to be surmounted when seeking treatment. These barriers also depend on gender.
One of the barriers is the stigma that comes with the problem. While the two genders are “stigmatized on seeking treatment, women are more susceptible to the stigma as compared to men” (Siegel & Welsh, 2011, p. 94). On the treatment outcomes, both genders respond equally to the treatment though there are a few instances where women respond better as compared to men. On relapse, women tend to show more instances of relapse than men do.
Age
To develop an effective treatment plan for adolescents, the plans used for adults have to be modified. Treatment for juveniles requires comprehensive assessment, treatment, and case management. They also need to be supported appropriately during this delicate age and stage of development.
In this case, assessment is vital because not all of them need treatment (Siegel & Welsh, 2011). Effective treatment of adolescents requires a family-based format that ensures family functioning and involvement. Age also affects the type of drug abused by the juveniles. In most cases, they are associated with light drugs, which are cheap and locally available.
Ethnicity
Some communities would fail to take the treatment due to ethnic stereotypes. For example, if the therapists are not of the same ethnic group as the client. This aspect brings out the fear that the therapist may not understand the problem properly, and thus the treatment would not be effective (Paniagua & Yamada, 2013). Additionally, the location of the treatment facility could bring ethnic inclinations into the process.
If the treatment facilities are not located in accessible geographical areas, people with abuse problems may not consider seeking treatment due to inaccessibility. For instance, the minority groups in the United States may refrain from visiting treatment centers in some locations because they are not supposed to frequent those areas. Besides, if the facilities were very close to the people, there would be concerns about confidentiality given that the therapists reside within the community.
Treatments for substance abuse should focus on the development of options that are ethnically sensitive. When values, histories, traditions, experiences, and resources of a given culture are involved in the treatments, they add some benefits to the individuals who are taking the treatment.
Ethnic dynamics such as inequity, discrimination, and migration among others should not be underestimated in evaluating an individual’s background and development of the treatment. These factors may influence self-efficacy, communication, family involvement, motivation, and therapist style.
Description of the Treatment
Before deciding a treatment for an adolescent, it is recommended for an assessment to be carried out. This assessment determines the level of the problem so that the best approach to treatment can be selected. Joseph is assessed at the center, and the treatment proceeds as described below.
After arriving at the treatment center, components that require treatment include substance abuse and family issues. Therefore, the Multi-systematic Therapy (MST) will be adopted for Joseph. The victim will be taken through the four stages of therapeutic community, viz. orientation, phase one, phase two, and finally community re-entry (Hanser & Mire, 2011). The orientation stage will help Joseph to understand the program’s philosophy, rules, and concepts that build the foundation of the process.
The orientation stage will be successful if the victim at the end of the program will be in a position to recite the rules and philosophy, write his life story, and complete the orientation workbook. Additionally, at this stage Joseph attends six orientation groups and class every day. During the orientation process, his mother and brother will attend family orientation groups once a week to understand the expectations of the program as well as the rules.
Due to his aggressiveness, he may not be willing to take orders from supervisors. Therefore, he is reminded to follow directives of his supervisors. This goal is achieved by reminding him to follow the slogan, ‘act as if’ to mean that he is willing to follow the rules even when he does not.
After Joseph has attended adequate classes of substance abuse, can recite the philosophy and rules, write a compelling life story, and completed the orientation workbook, he is promoted to phase one. At this point, his family members are considered to have attended adequate family orientation groups.
In phase one, Joseph is assigned an area of work within the community. Instead of reciting the rules, at this stage the victim is expected to adhere to them. Moreover, he is expected to learn to become more accountable and responsible to himself and other members of the community.
From these qualities, he advances to the next stage. A simple measure for this phase is ‘holding his peers accountable’. When a resident (Joseph) sees one of his peers violate the rules, he is expected to report (via specified ways of reporting) the peer to let the community know the violation. If Joseph demonstrates this attribute, then he is ready for the next step.
In the last two phases, Joseph is in the process of transition and reentry into the community. The focus is on rebuilding connections and preparing to get back to the community. The stage involves looking for employment, education, and house or home to live. Additionally, the stage prepares community connections for Joseph by preparing trips to resource centers, government offices, and libraries. Once these are set, the client is released officially to reunite with the family.
As a way of monitoring, therapists may interact directly with community institutions on behalf of the client and family. Additionally, after the treatment days, the client is encouraged to utilize accomplishments such as communication skills to refuse to offer drugs in the neighborhood. Joseph’s mother may help him to communicate effectively with the probation officers or prepare for job interviews.
Moreover, the therapist may prepare the family on how to tackle future problems like lapse and conflicts among others. Helping the family to anticipate proper solutions increases the possibility of responding positively when such problems arise.
The post-treatment process is terminated when the drugs used and the problem behaviors are reduced, when problem-solving styles and interaction patterns are developed, and they occur in absence of the therapist, and when the family acquires motivation skills and resources to maintain a positive behavior without support of the social workers (Leukefeld, 2011)
Ethical and Legal Issues
In this treatment, three ethical and legal issues will be considered. They include confidentiality, how to help parents find suitable treatments for their children without adjudicating the condition, and advocating the offender to remain on probation to complete the treatment.
On probation, there is much information required by the involved officers and parents usually want detailed data about the treatment progress of the client. Consider a case where a drug addict client on probation reports that he has started using the drug again. To overcome this challenge, the therapist must balance the legal mandate and report this violation to the therapeutic rapport by noting how hard she or he has worked to establish a relationship with the client.
The therapist has to decide how the information in the context of the gains made by the treatment while at the same time understanding the consequences associated with revealing it (Paniagua & Yamada, 2013).
In some cases, clients in probation complete their probation procedures while still undergoing treatment for abuse. When this scenario plays out with youths in residential treatment like therapeutic communities, it implies that they are free to leave the treatment if their period is not extended. In this case, therapists have an ethical issue to consider, viz. they have to decide to support the client outside probation and reduce their chances of recidivism, or request for the probation to be extended to complete all the treatment stages.
In the last ethical issue, parents who have limited resources have to decide whether their children have to be adjudicated to receive substance abuse treatment. In some cases, adjudicating a youth addict makes him/her together with his/her parents eligible for a better treatment package.
This assertion holds because of the high expenses associated with private treatment facilities. In many occasions, therapists are in situations where families have to decide on formal adjudication of their children addicts (Pollock, 2014). Therapists can solve this situation by acting like a case manager, and helping the family to find treatment without adopting formal adjudication. If the attempts are not successful, then it becomes an ethical dilemma.
Treatment Outcome Models
Three models could be used to measure the outcome of the treatment method adopted for the scenario. To justify the best model that could be used to measure the treatment outcome, the three models are discussed briefly, with emphasis on their challenges about the given scenario.
The Relapse Model
In a relapse, the client returns to a previous state of behavior that s/he was being treated or a mental problem (Hanser & Mire, 2011). This model supports other disease models, and it is related to both psychological and medical models. It constitutes the entire process, which is specific to only the affected clients.
This model is similar to a regular event that can be tackled by the treatment. This relapse model matches with several other medical and psychological behavioral models. When using this model to measure treatment outcomes, if the behavior reoccurs only once, then it does not qualify as a treatment failure. In a case of criminal justice where there are costs of reporting such as sanctions, the victims are likely to hide the reoccurrences because they fear the consequences (Hanser & Mire, 2011).
The instances of relapse are reported, and they attract sanctions. Joseph could hide some of the relapses that he experiences because he fears the sanctions. Besides, according to the model, if a lapse happens once, for instance, Joseph is taken back to court, the model terms this aspect as a learning point. Since what is expected is total abstinence from abuse and related behaviors, the standpoint of this model cannot be used to determine the success of the scenario being analyzed. Therefore, the model cannot measure accurately.
The Recidivism Model
In this model, the success is measured by whether the client returned to the judicial system or not. The reason as to why the client returns to the judicial system is not important (Hanser & Mire, 2011).
If Joseph returns to the judicial system, therapists are interested in knowing if it is due to a drug-related offense. If they know the reason is drug-related, this knowledge could help them to adjust the treatment to cover the gaps causing the recidivism. Reporting that Joseph returned to the court without giving any reason is not sufficient. Therefore, the model is not suitable to measure the success of the case study treatment process.
The Harm Reduction Model
When using this model, the success of the treatment happens when the client causes less harm after going through the treatment, as compared to when not taking the treatment at all. In the scenario, Joseph was initially abusing drugs. In the second instance when he was caught with the drug, he did not fight with the police.
This aspect was a success in treatment because there was reduced harm. This model factors in both the number of times the behavior is repeated and the resulting quality of behavior (Hanser & Mire, 2011). This model has one challenge, which it is not quantitative. The model describes the extent of the behavior using words instead of numbers.
Despite this challenge, it remains the best measure of success in the given scenario. Joseph has a substance abuse disorder, and he causes harm to his mother and brother. Therefore, only this model out of the three can measure the extent of Joseph’s harm reduction. This model can show how the harm that Joseph causes to his mother and brother reduces with time, as well as his avoidance of drugs.
References
Donohue, B., & Azrin, N. (2012). Treating adolescent substance abuse using family behavior therapy: A step-by-step approach. Hoboken, NJ: John Wiley & Sons.
Galanter, M. (2011). Psychotherapy for the treatment of substance abuse. Arlington, VA: American Psychiatric Pub.
Hanser, D., & Mire, S. (2011). Correctional counseling. Upper Saddle River, NJ: Pearson Education.
Leukefeld, G. (2011). Handbook of evidence-based substance abuse treatment in criminal justice settings. New York, NY: Springer.
Miller, M. (2013). Interventions for addiction: Comprehensive addictive behaviors and disorders. Amsterdam, Holland: Elsevier Science.
Paniagua, A., & Yamada, M. (2013). Handbook of multicultural mental health: Assessment and treatment of diverse populations. Amsterdam, Holland: Academic Press.
Pollock, M. (2014). Ethical dilemmas and decisions in criminal justice. Belmont, CA: Wadsworth.
Siegel, J., & Welsh, B. (2011). Juvenile delinquency: The core. Belmont, CA: Wadsworth/Cengage Learning.
Walters, T., & Rotgers, F. (2012). Treating substance abuse: Theory and technique. New York, NY: Guilford Press.
Weisz, R., & Kazdin, A. (2010). Evidence-based psychotherapies for children and adolescents. New York, NY: Guilford Press.