The role of theory in treating adolescent substance abuse

The adolescent substance abuser, like adult addicts, is most commonly considered from the perspective of the disease model. The usefulness of the disease model in conceptualizing adolescent substance abuse is questioned, and an alternative view of the topic is set forth. Substance abuse, is regarded as an adaptive aspect of the ongoing interactive processes within the family. The developmental process of the adolescent substance abuser is seen as a functional dynamic in the family's preservation. Three characteristic elements of parental interaction common to the development of adolescent substance abuse are highlighted.An earlier version of this paper was presented at the Texas Association for Marriage and Family Therapy annual conference on January 28, 1993 in Houston Texas.a research associate and director of the Don D. Jackson Archive at the Mental Research Institute, Palo Alto, CA. Authors are listed alphabetically.     

Child sexual abuse and adolescent prostitution: a comparative analysis

In several studies, child sexual abuse has been identified as a characteristic of adolescent prostitution. The implication of these findings, especially for girls, is that the two phenomena are related in that childhood sexual abuse perhaps leads to prostitution. The present study explored the relationship between sexual abuse and adolescent prostitution by comparing 70 sexually abused children with 35 prostitution-involved children on 22 variables. Findings suggest that the relationship is not directed, but involves runaway behavior as an intervening variable. It is not so much that sexual abuse leads to prostitution as it is that running away leads to prostitution. Implications for treatment of both sexually abused and prostitution-involved children also are discussed.     

Dual diagnosis: Clinical issues in substance abuse treatment

Dual diagnosis within the context of alcohol and substance abuse has become the focus of considerable interest, particularly when related to anxiety and depression. Depressive symptomatology is frequently associated with substance abuse and chemical dependency and numerous studies report a high concordance with these diagnostic entities and major affective disorder (Galanter,Casteneda, & Ferman, 1988). Depressive symptoms are also related to post treatment of alcohol and substance abuse with reported occurrences of 75 percent occurring with patients who have experienced relapse (Biedermann, Newcome, & Sprich, 1991).     

Prevention education and substance abuse treatment

Relapse prevention is influenced by a number of variables including stress and negative mood states, motivation and commitment to abstinence, social support, physiological factors, withdrawal symptoms, and a repertoire of cognitive and behavioral strategies utilized in responding to the relapse process. Diverse theoretical approaches have emphasized conditioning models as well as information processing, cognitive and affective components of treatment, cognitive and behavioral coping responses, and a variety of other procedures. Outcome studies related to treatment have failed to consistently support the effectiveness of several of these components. To overcomes this, the authors advocate a single subject design in the study of these approaches. This article emphasizes the role of relapse prevention, and training and education in facilitating long-term abstinence, particularly with those intervention methods that are based on social learning theory and cognitive-behavioral models.     

Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances

In this study, the authors examined the role of balance between adolescent-therapist and parent-therapist alliances in the retention of functional family therapy clients. Therapeutic alliances of mothers, fathers, and adolescents were assessed from videotapes of the 1st treatment session for 43 Hispanic and 43 Anglo families. Hispanic families who dropped out before completing the requisite number of sessions were found to have greater imbalance in alliance (parent-adolescent) than those who did complete therapy. However, this finding was not replicated with Anglo families. Results are interpreted in terms of previous research on family-level balanced alliance effects.     

Parent-adolescent relations and adolescent functioning: self-esteem, substance abuse, and delinquency

The present study examined parental support and monitoring as they relate to adolescent outcomes. It was hypothesized that support and monitoring would be associated with higher self-esteem and less risky behavior during adolescence. The diverse sample included 16,749 adolescents assessed as part of the National Educational Longitudinal Study. Both high parental support and parental monitoring were related to greater self-esteem and lower risk behaviors. The findings partially confirm, as well as extend, propositions in attachment theory.     

Cultural difference and the therapeutic alliance: an evidence-based analysis

The research on positive psychotherapy outcome consistently indicates that the quality of the alliance is important across different models of psychotherapy (D. E. Orlinsky, M. H. Ronnestad, & U. Willutzki, 2004; B. E. Wampold, 2000). Social psychological research has documented how "unintentional bias" can produce barriers to university admissions, employment, and advancement of well-qualified members of ethnic minority groups (J. F. Dovidio, S. L. Gaertner, K. Kawakami, & G. Hodson, 2002). Neuroscience is further confirming social psychological responses associated with race (J. L. Eberhard, 2005). Unintentional bias identified in social psychological research may be part of the psychotherapist/client interaction, interfere with the therapeutic alliance, and partly account for the high dropout rates and underutilization of psychotherapeutic services by people of color. The purpose of this article is to provide an evidence-based analysis of how psychologists in practice may unintentionally interfere with development of quality alliances with culturally different clients or patients and thus contribute to the barriers to effective multicultural counseling and psychotherapy. Principles from the American Psychological Association's (2003) multicultural guidelines and a review of relevant research are applied in suggesting strategies to reduce bias and to develop culturally appropriate skills in psychological practices.     

MMPI profiles of adolescent substance abusers in treatment

The non-K-corrected MMPI profiles of 243 adolescents presenting themselves for chemical dependency treatment in a residential setting were examined. Results suggested a general lack of psychopathology in this population, although a significant elevation on the Pd scale did emerge. These data are compared to the findings of previous studies with both adolescent and adult populations.     

Patterns of adolescent psychoactive substance use and abuse in Benin City, Nigeria

The pattern of use and abuse of psychoactive substances by Nigerian adolescents is investigated. Unlike previous epidemiological studies that used questionnaires to investigate university or postprimary school students, the present study used unobtrusive methods for data collection. The observed pattern of use was not different from that found in previous research. Adolescents tended to use the following drugs in decreasing order of frequency: alcohol, cigarettes, stimulants, cannabis (Indian hemp) and sedative-hypnotics. Polydrug use, especially of alcohol, stimulants, and cigarettes, is common. The use of hard drugs was not reported in this study. The implications of the findings can be appreciated only against the background of the known sequelae (psychological, physical, and socioeconomic) of psychoactive drug abuse. Finally, recommendations for controlling adolescent drug use are offered.     

Love in the therapeutic alliance

Volumes have been written about the patient's love for the therapist, but there has been relatively little discussion of the therapist's love for the patient. In an attempt to create a theoretical and technical space for discussing the appropriateness and role of love in the therapeutic relationship, a revised concept of the therapeutic alliance is applied to provide technical guidelines and understanding of two kinds of love between patient and therapist, corresponding to two systems of self-esteem regulation: an open, reality-oriented system and a closed, sadomasochistic system organized according to omnipotent beliefs. Examples of the role of love through the phases of treatment illustrate the interrelationship of love and the accomplishment of therapeutic alliance tasks.     

Distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility

A large percentage of individuals who enter residential substance abuse treatment drop out before completing treatment. Given that early treatment dropout places individuals at an increased risk for relapse, identifying the mechanisms underlying treatment dropout would have several important theoretical and clinical implications. In the current study, the authors examined levels of psychological and physical distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility. In a sample of 122 individuals entering a residential substance abuse treatment facility, level of psychological distress tolerance was predictive of early treatment dropout above and beyond relevant self-report variables. There was no relationship between physical distress tolerance and early treatment dropout. Implications for future studies and treatment development or modification are discussed.     

The development of therapeutic alliance during psychological assessment: patient and therapist perspectives across treatment

We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We hypothesized that a working alliance developed during psychological assessment conducted from a collaborative therapeutic model of assessment (TMA; Finn & Tonsager, 1992, 1997; Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We also hypothesized that alliance for those patients receiving a TMA would be significantly greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short Form-Patient Version (Hatcher & Barends, 1996) and the Combined Alliance Short Form-Therapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback session demonstrated positive and significant relationships with alliance throughout formal psychotherapy and in relation to a control group. The clinical utility and research implications of these findings are discussed.     

The concept of the therapeutic alliance.

Certain conceptual aspects of the therapeutic alliance are considered. Although therapeutic alliance, transference, and the real relation are intermingled and intertwined in the actuality of the analytic relationship, they remain distinguishable and open to differentiating analysis. The distinctions between the therapeutic alliance and transference, and between alliance and the real relation, are explored and their differences clarified, including the difference between therapeutic misalliances and transferences. Some of the component dimensions of the therapeutic alliance are explored, including empathy, the therapeutic framework, responsibility, authority, freedom, trust, autonomy, initiative, and ethical considerations including values and confidentiality. Further exploration of these and other dimensions of the therapeutic alliance is called for, especially the extension of these dimensions to their practical clinical application.     

Asociality and engagement in adult offenders in substance abuse treatment

In therapeutic community models for drug treatment, individual recovery is principally structured around group meetings and positive peer influences. Research shows that asocial group members with resistant behaviors and attitudes are at risk for poor treatment outcomes and have the potential to adversely impact the therapeutic group. To gain a better understanding of the asocial client's role in the larger treatment process, in-prison treatment data were used: (1) to model and confirm a two-factor solution of asociality consistent with the literature, and (2) to examine the relationship between asocial clients and treatment engagement for validation of the two-factor model. Exploratory analysis resulted in a three-factor solution representing behavioral responsivity, cognitive distortion, and social disassociation dimensions. Nested ANOVA (i.e., clients nested within prison programs) demonstrated that asocial levels (low, medium, and high risk) predicted treatment engagement. Furthermore, comparisons among asocial risk levels indicated that high asocial clients reported significantly lower engagement levels when compared with low and medium asocial clients. Copyright ? 2012 John Wiley & Sons, Ltd.     

Reciprocal relations between adolescent substance use and delinquency: a longitudinal latent variable analysis

Reciprocal relations between self-reported substance use and delinquency were examined through the analysis of 4-wave panel data collected from 1,218 high school students. A longitudinal, latent-variable framework was used to investigate interrelationships between changing patterns of generalized involvement in these 2 problem behaviors, while simultaneously accounting for specificity in drug use (e.g., marijuana use) and delinquency (e.g., theft). Analyses revealed that a model of bidirectional effects between polysubstance use and general delinquency was plausible for boys but not for girls. For boys, the effect of delinquency on substance use was small but consistent over time, whereas the effect of substance use on delinquency was larger but restricted to the earlier waves of the study. Implications for the question of whether or not substance use and delinquency have causal connections are discussed.     

The formation of the therapeutic alliance in couple therapy

This study examines the predictive validity of several clinical variables--including marital distress, individual symptomatology, and family-of-origin experiences--on the formation of the alliance in couple therapy. Eighty people who were treated with a naturalistic course of integrative conjoint psychotherapy at a large midwestern outpatient clinic were assessed on the clinical variables before session 1. They also completed ratings of the therapeutic alliance after sessions 1 and 8. Individual symptomatology did not predict alliance formation at either treatment stage. Higher levels of marital distress predicted poorer alliances to treatment between partners at session 1. Marital distress also predicted therapeutic alliance quality for men and women at session 8. Family-of-origin distress predicted alliance quality for men at session 1, and for women at session 8. Family-of-origin distress for men and women predicted split alliances early in treatment, and marital distress predicted split alliances for women at session 8. Clinical implications for the assessment and treatment of couples are discussed.     

Inpatient versus outpatient treatment of substance abuse: Recent developments in the controversy

There has been considerable controversy the past decade on which is more effective, inpatient or outpatient treatment of substance abuse. During this same decade substance abuse treatment grew into a $40 billion industry with for-profit hospital programs accounting for as much as one-half the total figure. Recently, controlled studies have replaced the previous research literature which was largely composed of uncontrolled studies. A research consensus is developing that states inpatient rehabilitation has no advantages over outpatient treatment and that even hospitalization for detoxification is unnecessary for 90% of patients. Implications for public policy are that we are over-spending in the treatment of substance abuse by misallocating resources to the most intrusive intervention.Nicholas A. Cummings, PhD, is founder and chairman of the board of directors of American Biodyne and president of the Biodyne Institute, president of the National Academies of Practice, former president of the American Psychological Association, and founder of the four campuses of the California School of Professional Psychology.     

Superego pathology in borderline conditions: Impediments to establishing a therapeutic alliance

Recent advances in the diagnosis and treatment of borderline conditions have imposed upon the clinician not only the task of a clearer differential diagnosis, but the finer job of diagnosing those factors which may speak for the patient's capacity to build up a growth-inducing working alliance. Among such factors, considerations regarding superego functioning have a crucial importance. In this work, a brief exploration of structural defects in borderline conditions, particularly superego-related defects or malfunctioning, is illustrated with three clinical vignettes. Some treatment considerations conclude this work, namely, considerations related to: the therapeutic frame; the facilitation of superego growth; and some notes on sectors of therapeutic mis-alliances and interactional symptoms and syndromes.