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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.

1.3 Theoretical Rationale/Mechanism of Action

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.

1.5 Conception of Drug Abuse/Addiction, Causative Factors

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.

2. CONTRAST TO OTHER COUNSELING APPROACHES

2.1 Most Similar Counseling Approaches