A teenage boy smokes marijuana
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The problem is that most treatment programs do not give teens a choice about 12-step attendance; it is usually a mandatory part of rehab or is in some cases legally mandated by a court.
Although individual and family therapy have shown more success with teen drug users than group treatment, most programs continue to use problematic approaches. One reason is cost. Group treatment allows a therapist to see many more patients in a day than individual sessions would. "If you can have four groups a day, you're going to do a lot better [financially] than if you have seven or eight individuals," says Szapocznik, noting that if insurers would pay for individualized treatment according to patient instead of by the hour, treatment for single patients or families could be made affordable.
The 12-step model also remains popular in part because such meetings are free and widely available. What's more, given that about half of addiction counselors are recovering addicts themselves, they tend to stay true to the treatment that worked for them — usually a 12-step program — and are not often well trained in other approaches like family therapy.
Some experts worry that unfavorable treatment strategies may only increase with forthcoming revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of psychiatry. In the current edition of the DSM, substance problems are divided into two diagnoses: "substance dependence," which signifies severe, chronic addiction, and "substance abuse," which applies to the kind of short-term risky behavior that many teens engage in but tend to outgrow.
In the proposed fifth edition of the DSM, however, diagnoses will be divided by drug, then by severity, all under the umbrella category of "addiction." That would mean the label of "addict" may be applied equally to a college binge drinker and a long-term heroin addict, which would not only reinforce the negative labeling effect on teens but also encourage mixing patients with varying substance problems in group therapy. "Failing to make the distinction at diagnosis will contribute to failing to make distinction in treatment," says Dr. Allen Frances, emeritus professor of psychiatry at Duke University and chair of the DSM task force that was in charge of the fourth edition.
What impact the new diagnostic categories may have remains to be seen. For now, researchers say the evidence shows the most effective teen drug treatment involves nongroup settings, especially for young people whose drug habits have not evolved to include harder substances. Anders Hoff, 23, says he was able to overcome his alcohol problem through individual therapy and by avoiding groups that required him to bear the label "alcoholic." At 18, Hoff left his home in Minnesota to attend college in Vermont. By the end of his first semester, he had developed a drinking habit so severe that he was frequently falling down drunk and suffering concussions. He had powerful headaches, and his senses of taste and smell were damaged by brain injury, but he didn't stop binge drinking. Panicked three days before the end of the term, he says, "with a knot in my stomach, I called my parents, said I had a problem and told them I had to go home."
He began individual counseling for alcoholism with Bob Muscala, a nurse in private practice in Edina, Minn., who has worked in the addictions field for 40 years. Hoff had two slips during his three years of therapy, but unlike with the standard 12-step program, his stumbles didn't force him to go back to zero and start counting his sober days all over again. "It didn't make me shut down and say, 'I'm done, let's start again with my old behavior,' " says Hoff, who is now back in school. "When I admitted the incidents, no one said, 'Well, you're an addict. You're never going to stop.' "
NIDA is funding collaborations with drug-treatment programs throughout the U.S. that are aimed at bringing both youth and adult treatments in line with practices that are known to work — for teens, that means family therapy, selective groups or individual therapy that prevents prolonged teen interaction in waiting rooms or other common areas. "There has been an incredible acceptance of evidence-based treatment" in programs that have joined NIDA's initiatives, Volkow says; however, many more community-based programs are still using interventions that have not proved to work.
Meanwhile, some individual treatment providers, like Muscala, continue to do their part, reducing drug use in the U.S. patient by patient. Matt Thomas, who has been in counseling with Muscala for about a year, just celebrated 10 months of sobriety at age 41.