With the privatization of imprisonment and the mutually parasitic relationship developed between the judicial system and drug counseling, the societal ill of chemical dependency has reached new heights of big business. Recently, a client being treated for chemical dependence and ADHD within an alternative high school in upstate New York was coerced into signing an intake to an inpatient drug treatment program. He had been a regular marijuana user on a PINS diversion and entered an outpatient program to appease his probation officer.
Upon admittance, his new drug treatment counselor told him that he only needed to give her two months and she’d fix him. Soon after, he turned eighteen and was still not completely clean. After roughly two weeks of outpatient services, his probation officer took it upon herself to contact his outpatient service provider and make a clinical recommendation that he be placed in an inpatient facility. The counselor complied without consulting his counselor or any of the three drug treatment counselors that this client was working with at his school. When the client was informed that he was not required to participate in the program, he returned to the outpatient clinic, asked for his signed paper back, and tore it up. Immediately after this display of independence, his probation officer closed his case.
From this experience the question may arise, why, after so much effort has been made toward deinstitutionalization, has the trend not affected drug treatment initiatives? It is the purpose of this paper to ponder the possibility that improvement in outcomes may be made if drug treatment for adolescents reassessed their foundational principles and refocused their efforts on treating underlying issues and developing new, healthier identities for young clients who abuse drugs.
Grella & Joshi (2003) contend that, for teens with a history of abuse and/or trauma, mere drug treatment is simply not enough. If the example client’s outpatient drug treatment counselor had been willing or able to spend time with him, she would have known that his history included trauma and violence. One may wonder if she would have been so willing to push the recommendation of a non-clinician had she just listened, rather than rely on conjecture, label him as resistance to her treatment, and sent him packing. Inpatient services may be a key factor for adults who need a revamped identity, complete with new social structure, belief system, uprooted sense of self, and rituals to keep this new identity on track; but, adolescents haven’t developed that self yet and therapy should refocus its efforts on fostering the identity beneath the addict while the chance still exists. Instead, mainstream society chooses to take an absolutist stance and require clients to suffer the process of conforming to a rigid, bureaucratically-based conceptualization of treatment.
What this paper is about is identity and asking the question, is it good practice to assign the identity of “addict” to a population developmentally defined by their role confusion?
The current state of drug court programs and the inpatient services they utilize more accurately reflect the values of the corrections system in America than those inherent to the field of mental health. Rounds-Bryant et al. (1999) found that a disproportionate level of African American and Hispanic males is sent to long-term inpatient programs, while white females often more disproportionately populate short-term inpatient programs. They recommend a general shift toward community-based programs and that more attention be paid to comorbidity, such as the depression that incited the initial use of drugs. Similarly, DeMatteo et al. (2006) find that little is done to differentiate between high and low risk clients, and that few alternatives to inpatient services exist for low risk individuals within the current drug court system.
A brief history of inpatient services may trace its origins to Charles “Chuck” Dederich and Synanon, which was set up as an alternative to AA. Synanon was a self-sufficient community for addicts, which was not reliant on government funding or insurance. It required a life-long commitment to sobriety and participation in community-based rituals designed to enhance cohesion among residents and replace the ritualistic behaviors of addicts and the enabling environment of their natural worlds.
Though this program came under strong criticism and underwent radical changes, which included the ejection of Dederich, it laid the foundation for future treatment communities that would sacrifice their methodological authority in exchange for government funding and insurance reimbursement. This stunted any real innovation in treatment by rendering these programs to the status of “one trick ponies,” reliant on consistency in outcome statistics to ensure future funding. Also, these programs became increasingly reliant on drug court programs for referrals due to the contradictory criminal conceptualization of addiction and the legal consequences of use.
The mental health community has, for a long time, adopted the disease model of addiction. That is to say, once an addict, always and addict. The legal system has continued with the typical corrections model that adopts a “lock them up,” segregationist policy. When these two ideas merge, as they do in inpatient services, the question arises, are we supposed to throw these individuals in “rehab” for life just because they suffer from a criminalized disease? This contradiction may best be explained through the metaphor of the three F’s, which are force, facts, and fear.
Drug treatment counselors may tell you that there is no hope for long-term success if we focus on any of these three F’s. Probation, with its threats and consequences, represents the tactic of force, treatment communities and other institutionalized tactics represent fear, while programs like OASAS, D.A.R.E, and NIDA often rely on facts to steer clients and potential clients away from drug use. In his article titled “Strange Bedfellows: The Tension of Coerced Treatment,” Whiteacre (2007) explored the paradox inherent to a drug court system that presents itself as rehabilitation but is actually relying on threats to coerce individuals to feign compliance. Whiteacre points out that the staff at inpatient facilities rationalize their clinical failures by claiming that juvenile clients are simply not “ready” for treatment, a reaction also made by the outpatient clinician in the example at the beginning of this paper. This narcissistic bias is seen in the literature as well. For instance, Jainchill et al. (2000) claim to support the use of treatment communities, but bias their outcomes by presenting the findings in terms of those who completed treatment and those who did not, harking back to the rationalization that clients weren’t motivated. Undoubtedly, this is not only poor science but unethical treatment. Whiteachre also points out that there is much disagreement between the staff as to the appropriateness of rewards and punishments, implying that the cohesiveness of their efforts can be characterized as frail and confused.
Confusion in the reward structure has, in the past, resulted in treatment facilities promoting cigarette use for drug offenders. This has the potential for strongly adverse effects over time. Meyers et al. (2007) report that individuals who had undergone alcohol and other drug treatment during adolescence were more likely to smoke at an eight year follow-up assessment, indicating a trend of transferring addictions to a culturally/legally acceptable substance.
So far, much attention has been given to the flaws present in the current model of inpatient drug treatment for adolescents. But, what works and how does this distill down to identity issues? Much research is dedicated to finding the key ingredient to personal change. In their study, Harpaz-Rotem & Blatt (2009) found that changes in clinical functioning were a result of the level of differentiation-relatedness of the counselor and the relationship built between that counselor and client. In summary, the relationship is key!
Frank Gough, a drug treatment counselor at the Dutchess alternative high school, stresses honesty in his clinical relationships. He utilizes honesty and rapport to uncover the internal perception of self from beneath the cluttered outward perception that has done so much to suffocate the adolescent individual. He finds that, through mutual openness and honesty, he is able to gain his client’s “permission to intervene.” This requires a strong sense of confidentiality, however, which is often ignored, if not rebuked, in the drug court system. The importance of confidentiality to adolescent clients cannot be overstated. In fact, McGuire et al. (1994) found that teens seek relationships with more confidentiality than they expect to receive, even when they are able to clearly differentiate between their ideal relationship and the legal demands placed on a mental health service provider in terms of breaking confidentiality.
Lutze & van Wormer (2007) make a general call toward the use of evidence- based practices within the drug court system in order to better serve the diverse mental health needs of the drug treatment population, which, more often than not, present with comorbid symptoms. This means siphoning out the biased studies of unethical researchers who have a vested interest in maintaining the status quo. The method of intervention proposed by Harpaz-Rotem & Blatt, and that used by Mr. Gough, may be difficult to test and earn the descriptor of evidence-based practice, as it relies heavily on the personal characteristic of the counselor. Lutze & Wormer, however, seek merely to enhance existing drug court programs, which may be inherently flawed, and not seek to reconceptualize rehabilitation and refocus it on recovering the client from drowning in the chemical.
Perhaps a more gestalt approach is needed to reduce substance abuse and dependence. For instance, Ford et al. (2007) suggest that programs must be able to treat trauma in order for clients to get the most out of their drug treatment. Consider that, without the ability to work through underlying motivations for use, substance abuse issues are bound to re-direct and re-emerge. For many adolescents, who are accepted by all followers of Erikson to be in the throes of individual discovery, substance abuse is an expression of an underlying disorder and inpatient services, fueled by an often-misguided drug court system, are inadequate for addressing those underlying issues.
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