Research Question: What are the key factors for success in adolescent

substance abuse recovery, and how can these factors be best implemented into

an ideal treatment model?

Julia Downing

Senior Project Advisor: Ashley Carruth

Abstract:
Substance Use Disorder (SUD) refers to an inability to limit or control the use of
mind-altering substances, causing an inability to function in society; it is becoming an
increasingly large problem in the adolescent demographic. As substance use disorders develop
and progress, adolescents face devastating consequences that can impact the entirety of their
lives. While incurable, SUDs are treatable and recovery is possible. In recent years, there has
been a growing need for innovation in the field of substance use treatments. This paper
explores the key factors that lead to success in adolescent SUD recovery, as well as reviews the
most effective methods of treatment for implementation of those factors. This research draws
on a variety of psychological and social studies, as well as focus groups, clinical interviews,
and surveys. The research points to five main internal and external factors, including dual
treatment and self-efficacy, as being essential for success. In terms of treatment
implementations, the research has found positive outcomes from thorough assessment, using a
variety of therapeutic modalities, and continuous care. These findings stipulate the need for a
holistic approach to recovery that centers around resilience and the overall well-being of the
individual. However, further research on long-term success in recovery is recommended.

12th Grade Humanities

Animas High School
March 1, 2024

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 Part I: Introduction

When it comes to teenagers and illegal substances, the news is not good. In 2022, it was

estimated that in the United States, roughly 48.7 million people over the age of 12 had a

diagnosed Substance Use Disorder (SUD), and 70.3 million had used illicit drugs in the past year

(SAMHSA). In 2017, a survey conducted by The National Center on Addiction and Substance

Abuse reported that nine out of ten people with a SUD started using before the age of eighteen

(qtd. in Johnson County). Adolescent substance use has significantly increased over the past few

decades, and since the COVID-19 pandemic, drug-related overdoses doubled in the adolescent

demographic (Panchal, et. al). According to the National Center for Drug Abuse Statistics,

substance use in 8th graders has increased by 61% from 2016 to 2022 (Teenage Drug Use

Statistics). In response to these alarming rates, new research and observations have been

conducted in hopes of creating more effective treatment options. Originally, all SUD treatment

methods were tailored for adults and approached treatment aggressively, failing to recognize the

unique characteristics of adolescents and contributing to the stagnation of teen recovery

(Winters, et.al). However, now more than ever, there has been an emphasis on innovation in the

field of addiction recovery targeting the needs of the impacted youth.

Unfortunately, only a small percentage (7%) of all diagnosed adolescents will receive the

help they need, due to cost, a lack of consistent and available treatment programs and services,

low motivation, and poor health care (Winters, et.al). If adolescents with substance use disorders

aren’t treated effectively, not only do they run a higher risk of developing issues later in life, but

they are in danger of facing devastating and potentially fatal consequences including legal issues,

disease, sexual and physical trauma, decreased mental and physical health, impaired memory and

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cognitive function, poor work performance, difficulty in relationships, and in some cases even

suicide (Johnson County). As new research is conducted, it is becoming more clear that due to

the unique developmental stage of adolescence and the progressive nature of addiction,

substance abuse recovery must use a holistic, community-based method of treatment that

prioritizes the building of self-efficacy, the treatment of co-occurring disorders, and the

reintegration of the adolescent into society.

Part II: Context / Background Information

In order to accurately identify key factors and treatment implementation strategies, we

must share a common definition of the problem. A Substance Abuse Disorder (SUD) is a brain

disorder that causes a person to be unable to limit or control their use of drugs or alcohol and

may lead to a disruption in their ability to function in society. SUDs develop for a variety of

reasons. While it is not uncommon, and for some young people even “harmless” to experiment

with drugs and alcohol in their teen years, it can quickly progress into an abuse cycle when

certain risk factors are present including peer pressure, co-occurring psychiatric disorders,

trauma, poor family dynamics, and boredom.

When taking into consideration that the prefrontal cortex of the adolescent brain is

significantly underdeveloped, susceptibility to peer pressure, makes intuitive sense. The

prefrontal cortex is the part of the brain that is responsible for impulsivity, goal setting,

reasoning, and judgment. When teens experience social pressure from peers to experiment with

drugs and alcohol, their brains are not mature enough to assess the risk and make wiser

decisions with an eye toward the short and long-term consequences. As a result, when a teen is

predisposed to addiction from other risk factors listed above, they can very quickly develop a

dependence on substances (Winters, et.al).

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 Co-occurring psychiatric disorders are an additional, highly predictive risk factor that

often predicts whether a young person has or will develop a SUD. Co-morbidity is defined as

the presence of two diseases or conditions that are active and interacting simultaneously.

Disorders like bipolar disorder or depression are very common in the general population (Deas,

et. al). Teenagers with these mental health conditions, whether they are diagnosed or not, might

use substances in an attempt to self-medicate and manage their symptoms if their problems

aren’t being treated effectively. Importantly, co-morbidity is significantly higher in adolescents

than in adults, which points to the insufficiency of simply applying adult treatment models to

adolescents, as well as the need for a more tailored treatment approach for these young people.

Similarly, an adolescent runs a markedly higher risk of developing a SUD if they have

experienced major trauma, for example, sexual assault, physical violence, war, or extreme

poverty, or if they have immediate family members who currently abuse substances or have in

the past (Johnson County). Adolescents may turn to substances in an attempt to reduce or mask

any number of undesirable symptoms caused by these co-occurring disorders and complex

traumas such as panic attacks, paranoia, hallucinations, and suicidal thoughts.

In contrast, boredom, while less intense, can be a strong driver of substance

dependency. At the same time, teenagers are also in a transitional period that is fairly stressful

and characterized by heightened risk-taking and thrill-seeking behaviors. Like the prefrontal

cortex, the nucleus accumbens, the part of the brain that suppresses risks and rewards, and

contributes to an increase in thrill-seeking behaviors, is also immature in adolescents (Winters,

et. al). Boredom, and the “newly-seeded desire for independence, can cause impaired

decision-making” (Winters, et.al) and can lead to misuse and abuse of substances. When an

adolescent is lacking activity and structure in his or her life, he or she may turn to substances to

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keep them stimulated. However, as these substances release high levels of dopamine in the

brain, the activities that were previously exciting to the adolescent before using won’t satisfy

the drive for dopamine now instilled, creating a reliance on the substance.

After establishing the causes of substance use disorders and the need for an

adolescent-specific treatment approach and in order to conceptualize the factors for success,

there must be an understanding of what success looks like and how it is measured. It is often

assumed that abstinence is the primary marker of successful treatment. However, research is

showing that it may not be as important as it appears. Relapse is fairly common in adolescents,

resulting in a high rate of recidivism in treatment centers (Hennessey, et.al). Rather than

measuring success as the period of time a teen can go without using drugs or alcohol, it is

becoming more apparent that success should be based on a reduction in symptoms, an ability to

continue education, a progressive shift in mindset, an improvement in relationships, and an

ability to meet self-made goals (Winters, Hennessey, Cavanaugh, et.al). These different units of

measurement create a more realistic set of standards and expectations for the struggling teen

and allow for a more flexible and tailored method of treatment.

The challenge with measuring success based on these five factors, rather than on

abstinence, is that it is harder to make qualitative conclusions about the effectiveness of

treatment methods. For this reason, much of the literature has used abstinence to measure

treatment program efficacy, and as a result the data around recovery rates relative to these

qualitative factors is fairly inconclusive. The remainder of this paper will explore the key

qualitative factors for success, and the best practices for implementing them in a treatment

setting, taking into account broad research information and statistics, as well as data from focus

groups, patient reports, clinical perspectives, and real-world success stories.

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 Part III: Research and Analysis

Section A: Key factors

Based on the specific needs of adolescents and the markers for success in recovery, the

literature points to five factors that are crucial to the treatment of adolescent SUDs: 1) a

progressive understanding of recovery, 2) the building of self-efficacy, 3) family involvement,

4) peer-based community support, and 5) dual treatment for comorbid psychiatric disorders.

Understanding Recovery as a Process

Current research and best practices overwhelmingly agree that having an established

understanding of treatment outcomes – what recovery truly is for each individual – is essential

for a successful recovery and must be future-oriented and hope-based (Cavanaugh, et.al).

When adolescents first start their recovery journey, they are often overwhelmed and

unmotivated; the thought of never being able to use substances again seems impossible and

terrifying. As a result, they will be less likely to participate in a program of recovery. Matt

Selos, a therapist and recovery coach at Elevations RTC, a residential dual treatment center for

adolescents in Syracuse, Utah, routinely sees this dynamic with students when they first arrive

on campus. When asked to identify the most helpful tool for getting his adolescent clients

engaged in the recovery process, he identified the importance of “meeting them where they are

at.” Validating and acknowledging the child's current mental state from the very first encounter

helps young people feel safer to explore a life separate from their substances.

However, honoring a client's emotions as they enter is not, on its own, adequate for

setting up the recovery process for success. Students must also have a clear understanding of

what they are trying to accomplish and why; helping them capture a vision of life free of drugs

and full of the things important to them, including family and friendships, a full social life, and

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college and professional success, increases their motivation and willingness to engage in the

hard work that lies ahead. Donata Senda, MA and LMFT, and the clinical director and therapist

at Sustain Recovery, an adolescent treatment center in Orange County, California, summarized

this idea by stating that “... the adolescent needs to be able to have something to look forward

to.” Due to the underdeveloped prefrontal cortex, adolescents are often operating out of

impulsivity and, without a goal to work towards, this impulsivity can be hard to combat.

As impulsivity is often a result of short-sightedness, it is crucial that the adolescent

understands recovery as an ongoing process of change (rather than a destination) and that

receiving treatment is just the beginning of that process. The first step to this is re-prioritizing

abstinence. Although it is not by itself a marker of success, abstinence is a precondition for any

attempt at recovery. Since relapse is common among adolescents, a model that makes

abstinence the priority treatment outcome is setting them up for failure, such that if or when

relapse does happen, a teen will just be discouraged and most likely resort to hiding their use

so they aren’t seen as being a failure. In light of this knowledge, in 2009, a focus group was

conducted by The Substance Abuse and Mental Health Services Administration (SAMHSA) to

develop a recovery-oriented method of treatment for adolescent SUDs. There was consensus

on the need for emphasizing resilience in the process of recovery. In a model that establishes

room for relapse and focuses on an overall improvement in the adolescents' health and

well-being, the young person will be more resilient and hopeful about their progression even in

the case of relapse (Cavanaugh, et.al). Creating a concept of recovery that is future-oriented

and hope-based lessens the stigma around addiction and takes the pressure off of the child to

perform. An adolescent with this concept of recovery is going to be more intrinsically

motivated to engage because they have realistic expectations of what the process will look like,

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and are more able to continue their recovery following initial treatment.

Building Self-Efficacy

Once an adolescent has a future-oriented and hope-based understanding of recovery, the

building of self-efficacy becomes arguably the predominant factor of success in SUD treatment

and recovery. Self-efficacy is defined as “the belief that one has the ability to implement the

behaviors needed to produce a desired effect” (Kadden, et.al). Without self-efficacy, recovery

doesn’t last. A large part of maintaining desired treatment outcomes relies on the ability to

cope with outside triggers and stressors that initially caused substance abuse behaviors.

Psychologists have found that, “Self-efficacy was found to be a strong predictor of the

occurrence of coping behavior, level of performance, and perseverance in the face of difficult

problems” (qtd. Kadden, et.al). A young person is not going to change their thinking patterns

or behaviors if they truly don’t believe that they can. However, once they begin to see growth

and progression as a direct consequence of acting on their own values and choices, they

become more motivated to keep pursuing the desired results. Since recovery is based upon the

individual’s definition of well-being, it makes sense for the individual to be leading that

process. This is going to give them the best ability to succeed when they don’t have as many

guardrails or external accountability keeping them clean.

As all adolescents are in a transitional period, they more likely than not will gravitate

towards gaining independence and often oppose guidance or direction from authority. Thus, if

they can identify their own treatment and life goals, as well as what they view to be their

biggest barriers to improvement, they are going to be less resistant to the treatment process

since it is not coming from a controlling, authoritative place. One clinician working with a

student at a recovery high school described the time when she saw this idea come to life:

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 That happened with a kid here, C., he had two or three relapses, he’d been in treatment

for eighteen months, a long time, and got out, relapsed… he was the one who would

come in and tell us that he had relapsed, which makes it easier (laughs)… then he just

started digging in and really working the program. You know he has three weeks now I

mean and he’s doing the deal. (qtd. Hennessey, et.al).

In this case, when the student was given room to struggle with relapse, he was able to

take his time identifying his own motivation for recovering, and once he found that, his

engagement in programming increased and was able to progress.

Moreover, building self-efficacy directly affects the ability to change behaviors and

thinking patterns (Kadden, et.al). The adolescent has to want to change, or at least be willing to

see the need for change, in order to succeed. When looking at the correlation between

self-efficacy and success through the lens of abstinence, it was found that self-efficacy had the

highest correlation with one year of abstinence following treatment (Kadden, et.al). When a

teen has a sense of agency in their life, when they have goals and self-determination, they are

going to be more involved in treatment programming and less likely to go back to old

behaviors that don’t align with their current values.

Family Involvement

Although self-efficacy is shown to be extremely important, an adolescent cannot

attempt to recover without external support, pointing to the third success factor in adolescent

recovery: family involvement. Involving the adolescent's family in the recovery process is

crucial to success because the family system lies at the heart of the child’s social and emotional

development. Researchers have identified that adolescent substance abuse can be predicted by

a series of family-based risk factors, including familial conflict, abuse as children, and

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exposure to parents that used/use substances (Horigan, et.al). If the family is not involved in

the treatment process to mitigate these factors, the young person runs the risk of returning to a

home that is not safe and supportive of their well-being.

The aim of family involvement is not only to reduce these risk factors but also to

implement an equally impactful set of protective factors. These protective factors include

positive parenting, parental monitoring and knowledge, positive parent-teen communication,

attachment to family, opportunities for prosocial behaviors, and anti-drug rules and norms, and

are shown to significantly decrease substance abuse-related behaviors (Horigan, et.al).

Moreover, during the treatment and recovery process, it is important for family members also

to address their own problem behaviors as they relate to the adolescent. While most SUD

treatments focus on the adolescents themselves, parents also need to acknowledge they are part

of the problem (Cavanaugh et.al). Communication, or rather the absence of effective

communication, is usually a large part of how the family system needs to be fixed. When the

teen is in active substance abuse, they are often in direct conflict with the parent.

Communication is usually minimal, and the relationship is operating in a dynamic where there

is mistrust on both sides. There can also be a sense of enablement, or even when there is

communication, neither parent nor teen feels they are being heard because it's coming from a

place of defensiveness or fear (Selos). When parents acknowledge they are part of the problem,

this takes the pressure and stigma off the teen and helps them feel safer to communicate more

openly without feeling like they are a failure or a disappointment (Cavanaugh, et.al).

Family involvement is especially useful for adolescents because, unlike adults,

adolescents in SUD treatment will most likely return home to a parent or guardian following

treatment. As primary caregivers, parents are primarily responsible for assisting their children

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in transitioning from residential or intensive outpatient treatment back to a traditional setting.

In adolescents where parents were actively participating in programming, such as parent

support groups, family therapy sessions, and volunteering, the patient did better overall

(Hennessey, et.al). And, when parents can communicate openly and effectively with their

children and are able to hold their children accountable to their commitment to recovery, the

young person has a greater chance of success not only in abstaining from substances but also in

maintaining healthy relationships.

Peer-based Recovery

Families are not the only context in which a young person needs to recover. A

peer-based recovery community is critical for adolescent SUD recovery because it provides a

healthy alternative to mainstream culture, motivates the young person with positive peer

pressure toward sobriety, and enables them to learn and practice new skills in their peer

relationships. In June 2015, Johann Hari, an author and journalist with a background in

sociology and psychology, gave a TED talk claiming that the opposite of addiction is not

sobriety, but rather connection. People with SUDs often say that the most significant aid in

their recovery is just having someone who they can trust and who will stick with them through

good and bad times (Davidson, et. al). Having support systems outside of a clinical setting,

especially from people similar in age, turns the treatment process into a shared journey, and

sparks hope as adolescents are able to relate to others and see the progress other adolescents

are making in their lives.

There is no doubt that adolescents are easily influenced by their peers, and the desire to

fit in can work in both negative and positive ways. When a teen is spending all their time

around people who are using and behaving in maladaptive ways, that behavior becomes the

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new norm for them. For this reason, it is imperative for the adolescent to change their social

environment (Cavanaugh, et. al). Addiction can cause people to isolate themselves and have

low self-worth, and involvement in a positive community allows adolescents to build up their

self-esteem as they start to contribute to society and relate to those around them (Senda). In

other words, peer pressure can work both ways. As we put young people in recovery into a

community where other adolescents their age are doing step work, attending classes, staying

clean, having fun, and working hard in therapy, they will also sense the pressure of these

positive forces and healthily conform to community norms. Being able to replace unhealthy

peer groups with fun, recovery-oriented ones sets the adolescent up for long-term success.

In addition to creating an atmosphere of positive influence, peer-based recovery

provides additional accountability and support outside of a clinical setting. Kids might feel

more comfortable talking about their experiences and feelings with a peer their age who

understands what they are going through, versus an adult in a professional position (Hayes).

Oftentimes, because teens are at the time of their developmental stage where they are gaining

independence and are more likely to defy authority, it's important to have peer-based support

because it provides accountability and guardrails – it gives them an outlet that doesn’t feel like

it's coming from a place of authority. It also allows them to be able to practice how to have

healthy relationships with others. Involvement in peer-based groups teaches adolescents how to

be accountable and honest with others and sets them up to gravitate toward similar

relationships following treatment (Nash et. al). Involvement in these types of communities has

been shown to enhance motivation to complete recovery work, as well as provide the value of

true friendship and fun. These communities are essential to adolescent recovery because they

are something that becomes more important to invest in than using substances.

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 Dual Treatment

After identifying through the literature four of the key factors to success in adolescent

recovery, there is one that serves to bridge the gap between enabling factors and how these

factors should be implemented into ideal treatment. This concept is referred to across the

literature as dual treatment. Dual treatment is a treatment model that addresses substance abuse

at the same time as also addressing co-occurring mental health disorders. Disorders that are

commonly associated with SUDs include externalizing disorders, such as conduct disorder and

ADHD, as well as internalizing disorders including depression, PTSD, and generalized anxiety

disorder (Cavanaugh et. al). Unfortunately, the presence of co-occurring disorders greatly

decreases the chance of successful treatment and increases the risk of relapse (Deas). Along

with these disorders, many adolescents will also have experienced some sort of sexual or

physical trauma which plays a major part in their development of the SUD. Since the presence

of comorbidity is high in adolescents with SUDs, the treatment of any underlying disorders

must be integrated with the treatment of the SUD.

The simple fact is that researchers do not know whether the SUD or the psychiatric

disorder comes first; the two are correlated but there is no clear causal relationship. What is

clear through the literature review is that left untreated, they exacerbate each other. Child

psychiatry researchers at the University of Indiana, in their paper on a proposed model for

adolescent SUD with co-occurring disorders, wrote about the speculation that internalizing

disorders that develop in early childhood may lead to a deficit in interpersonal skills and

expectancies of drug abuse. However, there is no evidence that early intervention for these

disorders will prevent the development of a SUD later on (Hulvershorn et. al). Regardless, dual

treatment is necessary because if these disorders go untreated, they may lead to relapse down

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the road. Donata Senda doesn’t mince words on the topic of dual treatment, saying “I don't

think that it's possible to say, ‘I'm gonna look at the substances on their own and ignore the

mental health issues,’ because that wouldn't be beneficial.” Senda went on to argue that

substance use is often an indication of a lack of acknowledgment or attention to underlying

issues. To paint a picture, perhaps a child is abusing substances as a way to self-medicate to

manage their anxiety. The illicit substances mask the anxiety symptoms while failing to

effectively treat the disorder. In this case, the substance abuse will continue to progress, along

with the anxiety, because the young person is not getting to the root of the problem, only

burying it until it becomes impossible to hide. The substances have now become part of the

problem because the teen is dependent on them to function, and likely more anxious as they try

to hide their use and find ways to acquire more. To maintain recovery, substance use must be

looked at and treated as it interacts with other mental health diagnoses.

Section B: Implementations

To implement each of the five success factors most efficiently, the literature suggests a

recovery-oriented and individualized approach in four main areas: 1) assessment, 2)

therapeutic modalities, 3) setting and structure, and 4) continuing care. We will explore each in

turn.

Assessment

The first step in implementing the five key factors for success is to conduct a thorough

baseline assessment and diagnosis of the adolescent. The Diagnostic and Statistical Manual of

Mental Disorders, fourth edition, text revision (DSM-IV-TR), a compilation of mental

disorders and the criteria created to diagnose them, has specific criteria that must be met in a

patient for them to get a SUD diagnosis. However, these criteria are more appropriate for an

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adult who has been using substances for a long period of time. In contrast, adolescents, having

less experience using, may not meet all the criteria while nevertheless still having developed a

serious substance use dependency (Deas, et. al). The baseline assessment should take this into

account and perhaps use a more flexible set of criteria for adolescents. If not, struggling

adolescents run the risk of going untreated and developing a higher chance of needing more

intense treatment later on in life. In other words, the goal with adolescents is not to wait until

their disorder has become severe, but rather to catch the SUD as early as possible, probably

long before they meet the full DSM-IV-TR criteria, and allow them to recover young.

Along with a SUD diagnosis that accommodates the age of the patient, the assessment

should also look for any co-occurring psychiatric disorders present. Without this key piece of

information, it is unlikely that any further treatment will be productive due to the

connectedness of SUDs to comorbidity. Different disorders (internalizing vs. externalizing) can

affect the SUD differently and should be noted when crafting a treatment plan (Hulvershorn et.

al). As part of the assessment process, it is important to have a thorough consultation session

with the adolescent that identifies their history of substance use, family history, medical

history, initial motivation and willingness to engage in treatment, and any familial, legal,

educational, and health problems (Winters et. al). Every child has unique experiences and

elements in their life that can affect their treatment. Screening for all possible variables enables

the treatment team to craft and ultimately implement an individualized care plan customized to

the unique circumstances of the patient. A commonly used approach in the treatment field is

what’s known as “the wraparound.” The wraparound is a detailed process for developing a care

plan based on the adolescents' strengths and weaknesses, as they relate to the formal and

informal services each program offers (Cavanaugh et. al). Assessment and planning, when

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done in this manner, form the backbone of a recovery model that is built around the priorities

of resilience and self-efficacy, and carves out a path for recovery that is attainable for each

patient.

Therapeutic Modalities

Based on the needs of the individual adolescent, a wide array of therapeutic modalities

and services must be utilized to target each aspect of the disorder and any comorbidities. The

key factors for success are best implemented in a treatment model that integrates different

types of therapies and services, including Cognitive Behavioral Therapy (CBT), Motivational

Interviewing (MI), family therapy, group therapy, and Contingency Management (CM),

Research points to Cognitive Behavioral Therapy (CBT) as a particularly effective

method of treatment for SUDs. CBT is a form of talk therapy built on the premise that thoughts

cause behaviors and can assign meaning to themselves and their environment. CBT aims to

modify harmful behaviors through verbal processing (Winters, et. al). Adolescents seeking

treatment work with a therapist using CBT to develop self-regulation and coping skills, while

simultaneously identifying both the core problems that led to the SUD as well as possible

internal and external factors that could trigger a relapse (Winters, et. al). CBT is also shown to

be effective in treating co-occurring disorders such as anxiety and depression (Hulvershorn, et.

al), and is correlated to high levels of self-efficacy (Kadden, et. al). In a study called Project

Match, designed to measure the effectiveness of CBT in SUD patients, researchers “...observed

significantly higher effect sizes for psychosocial outcomes compared to outcomes based on

frequency or quantity of substance use” (Magill et. al). This is important to note because it

demonstrates that CBT is a productive treatment, not only for attaining abstinence but also for

attaining more holistic treatment outcomes that are both grounded in self-efficacy and account

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for comorbidity. In short, CBT is a primary and effective modality for treating adolescents’

SUDs by getting the adolescent to look deeper into their thoughts and behaviors, and

combatting their disorders from every angle. CBT aims to treat the disorder by treating the

person as a whole, fitting in well with a progressive understanding of recovery.

Motivational Interviewing (MI) is a newer, non-confrontational therapeutic approach

where the patient is led by a trained therapist asking a series of questions to identify their

personal goals and beliefs about their behavioral patterns (Winters, et. al). MI is crucial to

adolescent treatment because it allows the young person to experience agency in their life. By

setting personal goals, the adolescent’s motivation for recovery moves from extrinsic to

intrinsic, thereby increasing the chance they will continue to pursue recovery following

treatment (Nickerson, et. al). This type of therapy is centered around the teen’s strengths, and

aims to build resilience and motivation through optimistic future-thinking rather than

stigmatizing or punishing substance use and other maladaptive behaviors (Brown, et. al). In a

study conducted by doctors and psychologists in 2013 about the efficacy of MI,

“…results revealed that MI was associated with a delay in time to first use of any

substance after discharge, and reductions in the number of days of any substance use

and of marijuana use reported during the first 6 months following hospital discharge.

Moreover, those in the MI condition reported significantly greater reductions in

rule-breaking behaviors in the first 6 months, compared to the TAU group. These

results suggest that MI had positive effects on some of the substance use outcomes, and

an added benefit of decreasing rule-breaking behaviors” (Brown, et. al).

MI, when utilized to combat a SUD, has clear positive results not only in producing

abstinence but also in reducing symptoms (rule-breaking) of other disorders such as

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Oppositional Defiant Disorder (ODD). MI targets the building of self-efficacy while addressing

co-occurring disorders in its non-confrontational and patient-led approach.

Other therapeutic modalities that should be utilized in SUD treatment for adolescents

are both family therapy and group therapy. Since family involvement has been identified as a

key factor for success, it is only appropriate that family therapy is utilized in a treatment

model. Some research points to family therapy as the most effective modality in reducing drug

use when compared to other modalities (Horigan). Family-based approaches target familial risk

factors as well as communication problems, which is key to maintaining a stable support

system for the adolescent throughout their treatment. Group therapy can be conducted in many

different ways through music therapy, art therapy, and processing and discussion-based groups,

as well as through psychoeducation classes (Senda). These types of therapy are beneficial in

building rapport between adolescents going through treatment together, and supporting a

peer-based recovery community. Psychology Researchers at the University of Boston highly

suggest group therapy as a modality of treatment by stating, “The sense of belonging to the

substance use culture can increase ambivalence for change, particularly when measurable life

changes occur at a slow pace. In such cases, it is critical to establish alternatives for achieving a

sense of belonging, including both social connection and effectiveness” (McHugh, et al).

In a closed survey conducted by Julia Downing and taken by 17 adolescents who had

been through SUD treatment, 11 of them reported “fostering close relationships with peers” as

one of the top most effective parts of their treatment. Both family and group therapies work to

fulfill their respective key factors of family involvement and peer-based recovery as they

integrate community into the individuals' treatment process and make pathways for healthier

connections and relational skills to be built. These modalities also destigmatize substance use,

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creating a safe environment for the adolescent to explore their own conception and

understanding of their disorders and recovery.

All of these therapeutic modalities require some participation from the adolescent to be

effective. However, adolescents entering treatment usually lack motivation and willingness

upon intake (Selos). It can be quite challenging for teens with SUDs to become motivated for

recovery when they have just spent a period of time being constantly supplied with the instant

gratification that comes with the dopamine release from substances. For this reason,

Contingency Management (CM) has been used as a way to improve motivation and willingness

to participate in treatment. CM is a behavioral therapy that uses external reward systems for

positive behavior (Petry, et. al). In the context of SUDs, rewards or privileges might be

presented to a patient who has successfully passed a drug test or completed a goal set by them

and their therapist. Research conducted on intrinsic versus extrinsic motivation found that

extrinsic motivators such as CM are most effective when initial interest in the task or activity is

low (Nickerson, et. al). Additionally, the outcome of studies across the U.S conducted on the

effectiveness of CM for SUD treatment found that “…the contingency management group

were significantly more likely to maintain continuous abstinence throughout the 12-week study

period than the standard care group (5.6% v. 0.5%)” (Petry, et. al). These studies also found

that CM enhanced treatment retention (Petry, et. al). This information helps show that CM can

help promote early abstinence as well as encourage participation in treatment programming.

In contrast, studies have also found that extrinsic motivation can actually decrease

autonomy and self-efficacy in an individual as it interferes with the individual’s ability to

discover internal motivation for completing a task (Nickerson, et.al). For this reason, clinicians

and researchers suggest that perhaps CM is a helpful tool in the early stages of treatment, but

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should exist only as a tool to get an adolescent engaged in treatment long enough to build the

internal motivation to recovery. As self-efficacy is a key factor for success, an adolescent has a

better chance of maintaining long-term recovery if they are recovering for reasons of their own,

and not because they are expecting some external reward. In a recorded interview, clinician

Donata Senda gives an example of how CM is utilized in the treatment center she works for, as

she talks about finding things the adolescent enjoys doing and using that to motivate them. For

instance, if a young person really loves basketball, they will get to go outside and practice for

30 minutes once they have completed their therapy assignment. This type of CM builds both

motivation for participation while also building self-efficacy, as the adolescent gets to decide

the reward they are working for and connects SUD recovery to already identified positive

experiences.

Setting and Structure

While the specific therapies available are important, the setting in which those

treatments are conducted and the structure of how those treatments are sequenced and

combined also has an impact. Although there are currently many different available treatment

structures and settings being utilized today, research shows that a long-term residential

program is most effective when followed by an intensive transitional treatment period.

Residential treatment refers to a method of treatment where the adolescent lives away from

home in the treatment center under 24/7 supervision and care of staff and professionals

alongside other treatment-seeking peers (Southerland). The benefit of residential treatment is

that it allows for the complete removal of triggers and temptations for use, essentially

enforcing abstinence to enable treatment to proceed. In a residential setting, patients are free

from outside distractions such as work, traditional school, social media, and social

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responsibility, making room for an intensive course of treatment programming that includes the

therapeutic modalities above as well. Peer-based recovery is also supported by a residential

setting because adolescents can live and experience treatment with other people their age. The

primary drawback to residential treatment is cost. These types of programs require a large

amount of funding, as they have to account for shelter, food, medical care, transportation, and

twenty-four-hour staffing by qualified professionals. Many families seeking treatment are not

able to afford such costs and resort to lower levels of treatment such as outpatient services,

where the child attends a facility for only a certain amount of hours a day.

As stated earlier, treatment recidivism is fairly high among adolescents. The National

Institute on Drug Abuse (NIDA), “…recommends substance abuse treatment to last at least 90

days; however, fewer than 25 percent of adolescents remain in treatment for this period”

(Cavanaugh, et.al). Data analyzers at Vista Research Group back up the NIDA suggestion after

finding that “…the longer a patient remains in treatment, the more likely they are to remain

abstinent” (Length of Stay). Vista researchers found that 44% of people who had completed

ninety or more days in treatment were able to stay abstinent for thirty days or more compared

to the 36% of people who had only completed thirty days. The duration of most adolescent

residential SUD treatment programs ranges anywhere from thirty days to six months. A longer

treatment stay is conducive to successful recovery because it gives the adolescent and the

clinicians time to address every aspect of the disorder and takes into account the need for a

level of trust and stability to be established between the adolescent and the professionals before

any type of therapy or programming can begin. Speaking from her many years of personal

experience in a clinical setting, clinician Donata Senda states firmly that in her experience

working with adolescents, “It's really important to make kids feel safe in the beginning. It's not

22
really in the beginning about trying to knock it all out. Yeah. Then it is really about just making

them feel grounded and settled in the moment." She also added, “Creating a sense of safety in

my experience has somehow helped with building that motivation.” Long-term residential

treatment is effective for these reasons as well as it gives the adolescent a completely isolated

experience from their familiar life that they can draw back on when they do leave treatment

and if relapse later on. They can look back on a time when they were completely abstinent

from substances and able to form healthy relationships, reach goals, and have fun without

drugs or alcohol.

Continuous Care and Transition

One of the drawbacks to residential treatment is the high contrast to a home setting.

When a child is in residential treatment, they are constantly being provided with accountability

and support which, although helpful, can set the child up for a bit of culture shock as they

reintegrate back into a more independent setting. Accounting for this and per an understanding

that recovery is a process not a destination, treatment for adolescent SUD needs to be

supported by a rigorous transition from residential care back to a home setting. This

transitional period is essential if the adolescent is expecting to maintain their recovery

long-term because they are going to be going back to the environment in which their disorder

developed. One medical doctor who was participating in a SAMHSA-conducted focus group

observed, “...the most likely time for an adolescent to link to continuing care services comes

within the first 1 to 2 weeks following discharge from residential care” (qtd. Cavanaugh, et.al).

One key element of transitional care is working with both the adolescent and the

adolescent's parents to create a recovery-oriented home contract and relapse prevention plan to

implement in their daily lives when they leave. The idea of a home contract is to implement

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structures and guardrails using the tools they’ve learned during treatment (Senda). Researchers

found a greater increase in self-efficacy after relapse prevention treatment when home plans

were implemented (Kadden, et.al). Home planning can involve setting up organized activities

for the adolescent to participate in, making contact with a local outpatient therapist for weekly

sessions, making a daily schedule to avoid boredom and maintain the sense of structure built

during treatment, and having a clear set of personal and academic goals to work towards

(Senda). Along with home planning, both individual and family therapy should be continued

following treatment to ensure that the new communication skills and behaviors are being

utilized effectively. Some treatment centers will offer a set of free sessions with their onsite

therapists for the first months of being home, and a part of the home planning process involves

making contact with an outpatient therapist that the adolescent will see once they leave a

residential setting (Selos). Having these systems in place supports effective communication

between parents and adolescents, and helps set realistic expectations and boundaries for the

adolescents as they reintegrate into society.

Treatments that implement a twelve-step approach into their programming support this

continuous care model by introducing adolescents to a recovery program that is free and easily

accessed from most towns across the country (McClernon, et.al). Twelve-step programs such

as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are addiction support groups

where recovering addicts attend recovery-oriented meetings as well as work closely with each

other to further their progress and celebrate clean time. After examining multiple studies and

surveys, it was shown that “beginning 12-Step participation while in treatment, especially at

group meetings held at the treatment program, and 12-Step attendance at the same time that

one is enrolled in specialty treatment, are associated with better outcomes” (Donovan). When a

24
young person leaves treatment, they will have an idea of where to go to get support for their

disorder at home by attending local AA or NA meetings. The twelve steps that these programs

are based on can support the adolescent as they set goals and continue to improve their life

(McClernon, et.al). Twelve-step programs are a great resource by providing a community of

other recovering addicts who keep each other accountable and optimistic about recovery.

Aside from twelve-step implementation and post-treatment planning, transition support

can be implemented by connecting adolescents to local resources such as outpatient programs

and therapists, academic support, and alternative schools that are more flexible to fit the

adolescent’s needs. An example of this is an emerging industry of education called Recovery

High School. High School 5280, the largest recovery high school in the country, located in

Denver, Colorado, is a project-based learning school where students can receive needed credits

and attend classes while also receiving direct support for their recovery through addiction

counseling and mandatory school-wide recovery meetings in a completely drug-free

environment (Hayes). The only requirements for attending this school are a willingness or

desire to stop using, and participation in a program of recovery outside of school (Hayes).

Keith Hayes, Director of Recovery at 5280, had much to stay about maintaining recovery after

initial treatment. In an interview in January of 2024, he spoke about the importance of

providing an abundance of structure and support for adolescents in recovery to make sure they

don’t “fall through the cracks.” He has witnessed first-hand the benefits that participation in

recovery communities and counseling gives to adolescents in recovery. He has seen students go

from failing out of school, dealing with legal repercussions due to drug use, and being unable

to accomplish anything, to graduating from high school, celebrating months and years of

sobriety, and enthusiastically participating in their communities and relationships. Alternative

25
Peer Groups (APG) like High School 5280 make transitioning from a residential setting

smoother because they provide adolescents with a functioning and healthy peer group to get

involved with right away, rather than running the risk of the adolescent returning to the same

group of friends they started using with before treatment. These APGs continue the work done

in treatment and support growth in interpersonal and intrapersonal relationships. In 2018, in an

interview conducted by researchers to look for efficacy in alternative peer groups, one

recovering adolescent stated,

“After 3 months I had a lot of trust in my family back. I felt better. I felt a lot healthier,

stronger, and better. My emotional state was better… My social anxiety got a lot better

over time. It took about five months… and then I had six months sober. I’ve been in

[APG] for like a year and almost a half now” (qtd. Nash, et. al).

Support services such as these that revolve around community destigmatize addiction and build

hope and self-efficacy in the lives of many recovering youths.

Part VI: Discussion/Conclusion

It is apparent through the literature review that adolescent SUD recovery is not a simple

process. Taking into consideration the complex nature of the adolescent brain, the various risk

factors, and the progressive nature of addiction, recovery must be approached holistically and

thoroughly. Substance abuse is often thought of as the problem, but perhaps it is more correct

to view substance abuse as a commonly sought-out solution to co-morbidity, lack of

connection, lack of understanding and empathy, and low self-efficacy. In an attempt to fit in

with peers, self-medicate, seek out thrills, or escape uncomfortable emotions, adolescents are

finding themselves waist-deep in a deadly disorder. At some point in an adolescent’s life,

substances had served a purpose. Eventually, however, those substances failed to sustain the

26
needs of the adolescent; and thus begins a cycle of using more and more to try to get them to

work again, but various social, emotional, familial, physical, and systemic problems start to

pile up instead.

In order to treat a Substance Use Disorder, it is imperative to look at the reasons why

the adolescent started using in the first place, and why they now cannot seem to stop. Taken

together, the five key factors for successful recovery become a replacement solution,

addressing the deeper needs that substances will never be able to meet. Understanding that

recovery is a process and a way of living, rather than a destination, gives adolescents a

structure and a vision of hope for themselves. They are empowered to settle into the changes

they are making rather than rushing through them or burning out and disappointing themselves.

Self-efficacy gives them confidence and agency in their life that they need to work towards

goals and to keep persisting towards growth even when they slip and fall. Family involvement

and peer-based recovery provide connection and morale so that never again will the adolescent

feel as though they are alone. Instead of using drugs to numb uncomfortable emotions, or using

drugs as a way of socializing, they have healthy people around them to process life with and

who know how best to support them. Dual treatment and the use of various therapeutic

modalities, when followed by a meticulous continuum of care, target the adolescents' disorder

from every angle. The young person becomes more aware of, and able to handle, the triggers

that life throws at them. It is when all of these pieces fit together that recovery happens.

Unfortunately, our society tends to only give disorders like SUD attention and care

once they have completely destroyed a person's life. Although most SUDs develop in

adolescence, most people won’t receive treatment until adulthood and by that time they will

have suffered tremendously. For this reason, it is imperative to begin treating adolescents as

27
early as possible. The earlier an adolescent is introduced to recovery, the less pain and

suffering they will have to go through to admit a need for change. There is a common phrase,

“rock bottom,” that refers to the lowest point in a person's life that often makes them realize

they need help. While pain and loss can be a great motivator for change, it doesn’t need to be

the only one. Research has proven that willingness and motivation can be planted and absorbed

into a young person's mind through therapy and community. All it takes is one person to know

what to look for and to see that an adolescent is suffering even slightly as a result of substance

abuse, and for them to intervene in a caring way. Donata Senda noted that “Kids are like

sponges; they absorb everything.” No adolescent sets out to become dependent on drugs and

alcohol; what they are looking for is connection, excitement, and relief. When done effectively

and attentively, treatment introduces recovery as a source for all three.

For future research, a more flexible way of measuring the efficacy of success factors

and implementations needs to be created. Across the literature, there were limitations around

concrete evidence of effectiveness due to a lack of patient tracking, and a clear set of success

criteria. It is hard to measure how effective treatment is because recovery is a life-long journey.

An adolescent might leave treatment and after a year go back to using, but as an adult, they

start to see their life becoming unmanageable and go find a twelve-step meeting, remembering

the things they were taught years before. Doesn’t that qualify as success? Situations such as

this are not accounted for in current research.

As SUD is a very complex topic, there are many additional avenues to research that

were not addressed in this paper, including more research on the current lack of resources and

funding available for adolescent SUD treatment, how that treatment should differ depending on

the substance of choice abused by adolescent, how harm-reduction education affects adolescent

28
SUD recovery, the use and efficacy of pharmaceutical and homeopathic medicine for SUDs

and, SUD prevention. Looking deeper at these subjects will provide more information on how

to effectively support adolescent recovery.

An important takeaway from both the literature review and from hearing from

recovering addicts and clinicians is that the goal of treatment is not to ensure the adolescent

never uses substances again or never struggles again, but rather to give them the tools,

community, and hope they need to make progress in their life. It is often said that recovering

addicts should strive for “progress rather than perfection.” With this mindset, treatment is not

about “fixing” the adolescent or forming them into something society deems suitable, but

rather about planting a seed of encouragement and hope. It is about making it possible for an

adolescent to see that life without drugs and alcohol is both achievable and worthwhile.

Recovery is not one size fits all, thus the best way to implement success is to meet the

adolescent where they are at and help them find their own definition of success.

29
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