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In addition, researchers find, the harm of many teen drug-treatment programs may come not only from the negative influence of new relationships but also from the degradation of positive bonds with family. In a 2003 paper, Jose Szapocznik, chair of the epidemiology and public-health department at the University of Miami, found that teens who used marijuana but still had healthy relationships with their families saw those relationships deteriorate and their drug habits increase when they were assigned to peer-therapy groups. Among these teens, who were in treatment for a minimum of four weeks, 17% reduced their marijuana habit, but 50% ended up smoking more. "In group, the risk of getting worse was much greater than the opportunity for getting better," Szapocznik says, adding that in contrast, 57% of teens who were assigned to family therapy showed a significant decrease in drug use, while 19% used more.
Although teens with fewer problems may be adversely affected by their more dysfunctional peers, the reverse can also be true: teens with severe behavioral problems actually improve when placed in groups with better-adjusted youth. The 2004 Cannabis Youth Treatment (CYT) trial, which included 600 teens, found that over the course of a year, marijuana use dropped 25% in teens in both group therapy and family therapy, no matter how severe their behavioral problems were.
CYT's success may be due to the fact that while its participants had varying degrees of behavioral difficulties, they did not differ significantly in terms of substance use the trial excluded anyone who had used any drug other than marijuana for 13 or more days in the previous three months. That factor alone may account for the across-the-board benefits, but in most teen rehab centers outside of research settings, patients continue to be lumped together with little regard for the severity of their drug problems.
It doesn't help either that the philosophy behind many drug-treatment programs can be easily misinterpreted by teenagers. Most programs in the U.S., including the one Thomas attended, are modeled after the 12-step recovery plan used by Alcoholics Anonymous. The first step encourages participants to accept that they are "powerless" over their addiction and to surrender their will to a higher force. For some people, it inspires mutual support and abstinence, but for others especially teenagers it can foster a feeling of defeat. "You get these 12-step teachings telling you that you're doomed, that you have this disease and this is the only way out," Thomas says.
Indeed, surrender is not a word that comes easily to teens, and teaching them to believe they are powerless may create a fatalism that leads to relapse, according to Andrew Morral, a senior behavioral scientist at the Rand Corp. In his studies of teens treated at Phoenix House, one of the largest treatment providers in the U.S., he found that participants who subscribed to the tenet of powerlessness were more likely to return to drugs after treatment, compared with teenagers who did not take the message to heart.
Still, for an estimated 10% of teen drug users whose addictions are severe enough that they already feel helpless to control them, the 12-step method can help. For example, a study published in July in the journal Drug and Alcohol Dependence found that teens who had severe addictions to alcohol, marijuana, heroin or painkillers and chose voluntarily to attend 12-step meetings once a week for three months had nearly double the number of sober days as those who did not attend. "People who go to Alcoholics Anonymous or Narcotics Anonymous and stick with it are the most severe cases," says study author John Kelly, associate director of the Massachusetts General Hospital Harvard Center for Addiction Medicine, while people with milder problems typically don't feel they "fit" and quit attending.